
Glass. 
Book. 



COPYRIGHT DEPOSIT 



TEXT-BOOK 

OF 

GYNECOLOGICAL 
DIAGNOSIS 

BY 

Dr. GEORG winter 

O. O. PROFESSOR AND DIRECTOR OF THE KGL. UNIVERSITATS-FRAUENKLINIK IN KONIGSBERG, PRUSSIA 
WITH THE COLLABORATION OF 

Dr. carl RUGE, of Berlin 



EDITED BY 

JOHN G. CLARK, M.D. 

PROFESSOR OF GYNECOLOGY, UNIVERSITY OF PENNSYLVANIA 



AFTER THE THIRD REVISED GERMAN EDITION 



ILLUSTRATED BY FOUR FULL PAGE PLATES AND THREE HUNDRED AND FORTY-SIX 
TEXT ILL USTRA TIONS IN BLA CK AND COL ORS 



PHILADELPHIA <5r^ LONDON 

J. B. LIPPINCOTT COMPANY 



LIBRARY of CONGRESS 
Two Ceoies Received 

JAN \Q 1909 

Oopvrlirnt Entry ^ 
M.WS ex- KU No, 

PY 3, 



COP 



.-^" 



Copyright, 1909 
By J. B. Lippi.\xoTT Company 



Elec.trotyped and Printed hi^ J. B. Lippincoit Cornpany 
The Washington Square ^■^I^ess, Philadelphia, U.S.A. 



'^ 



TO MY ESTEEMED 
MASTER 

ROBERT OLSHAUSEN 

THIS WORK IS DEDICATED IN UNALTER.^3LE 
GRATITUDE 



PREFACE TO THE ENGLISH EDITION 



The history of American gynecology is replete with brilliant achieve- 
ments, and much of the pioneer work of such pathfinders as McDowell, 
Sims, the Atlees, Hodge, Emmet, Skene, Goodell, and others, has been 
incorporated in the basic principles of modern diagnosis and treatment 
of the diseases of women. This work so conspicuously begun bj^ our 
countrymen has been worthily maintained by a large number of skilled 
successors, who are still in the zenith of their careers. 

Although much has been established in the practice of gynecology 
in the United States, we owe much nevertheless to English and Con- 
tinental gynecologists for the discovery and inauguration of many 
essentials in theory and practice, and especially must we pay tribute 
to the painstaking research of German specialists, who have been inde- 
fatigable co-workers in creating from a minor field a great specialty, 
which takes equal rank with other representative branches of medicine. 
To their epoch-making discoveries in embryology, to their careful 
elaboration of the topographical anatomy and histology of the genera- 
tive organs, to their infinite patience in the investigation of questions 
relating to the pathology and bacteriology of the diseases of women, 
to their establishment of various principles relating to surgical and 
therapeutic treatment, and to their faithful study of the ultimate results 
of operative measures we may attribute much of the progress of this 
specialty. 

Of the younger school of German gynecologists, Professor Winter 
occupies a representative position, and his experience as a teacher of 
gynecology, first in the University of Berlin, and later in the University 
of Konigsberg, has amply fitted him to write a practical book on gyne- 
cologic diagnosis, judiciously leavened, but not overburdened, with the 
science of this subject. The text is clear and concise, and is so effectively 
illustrated that all important points are brought out in sharp relief. 

In addition to the practical part of the book, which has been so 
carefully prepared by Professor Winter, Professor Carl Ruge, the dis- 
tinguished investigator and teacher of microscopic diagnosis, has con- 
tributed a very valuable section on this subject and its important bear- 
ing upon the etiology, diagnosis, and treatment of the diseases of women. 
That the laboratory must frequently be the court of final resort in the 
early diagnosis of cancer is convincingly demonstrated by this master. 



vi PREFACE TO THE ENGLISH EDITION 

Therefore, because of the merit of this German text-book, it is a 
pleasure to stand sponsor for this EngHsh translation. 

While in general the principles of gynecology are, with minor 
variations, identical the world over, nevertheless each country shows 
national preferences. In order to adapt this translation to American use, 
brief editorial annotations have been made here and there, which have 
appeared essential to the wider adaptation of the book to this country. 
These comments are contained in separate editorial paragraphs, enclosed 
in brackets, thus leaving the translated German text intact. 

To Dr. R. Max Goepp are due the thanks of the editor for his splendid 
translation, which has faithfully preserved the author's meaning and 
yet has clothed it in most attractive English. 

John G. Clark, 

2017 Walnut Street, Philadelphia, 1908. 



PREFACE TO THE THIRD EDITION 



The completion of the third edition has been very much delayed 
by other literary undertakings. During the ten years that have elapsed 
since the appearance of the second edition, gynecological diagnosis both 
clinically and pathologically has been greatly developed. With the 
increase in my experience and my removal to another field my views 
and their formulation also underwent certain important alterations. 
For this reason I felt it my duty to subject the entire text-book to a 
thorough revision and especially the following portions: general diag- 
nosis, extra-uterine pregnancy, retroflexio uteri, myoma, carcinoma of 
the uterus, diseases of the vulva and vagina, and diseases of the urinary 
apparatus. My collaborator, Carl R-uge, has rewritten his contributions 
to the book on a considerably enlarged scale. The illustrative portion 
also has received alterations and additions, the number of illustrations 
having been almost doubled. The clinical portion contains a number 
of new, mostly colored illustrations, prepared by the able hand of Miss 
G. Burdach of Konigsberg. Gebhard's photograms have been replaced 
by original drawings from the pencil of Mr. Richter. 

Once more I wish to express my sincere thanks to the publishing 
firm of S. Hirzel, of Leipzig, who have always shown their readiness to 
carry out my wishes, exacting though they might be. 

G. Winter. 
Konigsberg, February, 1907. 



PREFACE TO THE FIRST EDITION 

(1896) 



Gynecological diagnosis has made tremendous strides during the 
last decade. Above all, the method of combined examination has 
gained so much in accuracy, from constant comparison of the palpatory 
findings with the conditions revealed by laparotomies, that it now 
furnishes a reliable foundation for diagnosis. It is chiefly owing to 
combined examination that gynecological diagnosis has become a 
science and a study of considerable importance and extent. While 
every text-book on gynecology devotes a large share of its pages to 
diagnosis, this very fact not only justifies but indeed demands a special 
treatment of the subject; and, except for Veit's "Gynakologischen 
Diagnostik" (1890-1891), no text-book especially devoted to gyneco- 
logical diagnosis has yet appeared either in the German or in the foreign 
literature. 

The fact that I have for eight years been engaged in teaching 
gynecological diagnosis is my reason for writing such a book. During 
these years I have been constantly striving to perfect my subject and 
have had ample opportunity to test my views and manner of presenta- 
tion in the class-room. As for the requirements of the practitioner, I 
have tried to meet them by devoting special attention to those diag- 
nostic points which I have found to be most important in the many 
years of my close association with physicians. In this way I have closely 
followed my teaching in writing this text-book and accordingly hope 
it may prove useful both to students and to those engaged in active 
practice. 

A great deal of space has been devoted to microscopical diagnosis 
because I have become more and more convinced of its value. To my 
great joy, I succeeded in securing as a collaborator for this part of the 
work Carl Ruge, the creator and assiduous promoter of this method, 
so that his teaching and experience, which are of such great value to 
practical gynecology, are at last to be given permanence by appearing 
in printed form. 

With regard to the illustrations I have the following communica- 
tion to make: 

The microscopic illustrations I owe to my colleague Gebhard. 
They are autotypic reproductions of his excellent micro-photographs, 



X PREFACE TO THE FIRST EDITION 

and, owing to their absolute truth to nature, offer to the microscopist 
the surest foundation for his diagnosis. 

The illustrations which represent palpatory findings were obtained 
by making careful measurements on the living subject and transferring 
them to Schultze's rubber stamps, and they accordingly represent useful 
material for scientific purposes. 

The originals for the wood-cuts were prepared according to my 
directions by Mr. Paul Richter, can. med. of Berlin. 

I also wish to express publicly my thanks to Mr. Hirzel, of Leipzig, 

for his ever ready and obliging courtesy, which has made my association 

with him such a constant pleasure. 

G. Winter. 
Easter, 1896. 



The second edition appeared with very little change in 1897 and 
was translated into Italian. 



CONTENTS 



GENERAL DIAGNOSIS. 

PAGE 

External Examination 1 

Internal Examination 3 

Combined Examination 4 

Rectal Examination 18 

Examination of the Genitalia through the Bladder 20 

Method of Using Specula 20 

The Uterine Sound 26 

Dilatation and Palpation or the Interior of the Uterus 32 

Microscopic Diagnosis 38 

Exploratory Curettage 39 

Exploratory Excision 41 

Microscopic Examination (Ruge) 42 

Cystoscopy 52 

Bacteriologic Diagnosis 64 

Radiography 68 

The Making op a Gynecologic Diagnosis 68 



SPECIAL DIAGNOSIS. 

The Normal Findings 76 

Topographic Anatomy of the Female Genital Organs. Normal Palpatory Findings. . . 76 

Vulva 76 

Vagina 78 

Vaginal Portion 79 

Uterus 80 

Peritoneum 81 

Ligaments 84 

Ovaries 88 

Tubes 90 

Parametrium 90 

Bladder 91 

Ureters 94 

Rectum 94 

Bony Parts of the Pelvis 95 

Muscles in the True Pelvis 96 

Lymphatics and Lymph-glands 96 

Blood-vessels 96 

Histology (Ruge) 98 

Vulva 98 

Labium Maj us 98 

Bartholin's Glands 101 

Clitoris 102 

Labium Minus 102 

Hymen 102 

Urethra 103 

Vagina 104 

xi 



xii CONTENTS 

PAGE 

Uterus 106 

(a) Vaginal Portion 107 

(b) Cervix IDS 

(c) Body Ill 

Diagnosis of Noemal PsEGN.-iJSfCY 124 

Diagnosis of Pregnancy during the First Half 124 

Diagnosis of Pregnancy during the Second Half 129 

Differential Diagnosis , 131 

Diagnosis of the Disturbances of Pregnancy 134 

Diagnosis of Pregnancy with a Dead Fetus 134 

Diagnosis of Abortion. 136 

Diagnosis of Extra-uterine Pregnancy 143 

Diagnosis during the First Half of Extra-uterine Pregnancy 145 

Diagnosis during the Second Half of Extra-uterine Pregnancy 159 

Differential Diagnosis of Extra-uterine Pregnancy 163 

Rarer Forms of Extra-uterine Pregnancy 173 

Interstitial Gestation 173 

Ovarian Gestation 173 

Gestation in a Rudimentary Uterine Cornu 173 

Microscopic Diagnosis of Pregnancy (Ruge) 175 

Products of Conception and Changes Incident to Pregnancy 175 

Macroscopic Examination 175 

Microscopic Examination 178 

Microscopic Diagnosis of the Membr.anes Expelled from the Genitalia, especially 

FROM the Uterus (Ruge) 205 

Displacements of the Uterus and Adjacent Organs 211 

Anteposition of the Uterus 212 

Retroposition of the Uterus . 213 

Lateroposition of the Uterus (Dextroposition, Sinistroposition) 215 

Elevation of the Uterus 217 

Prolapse 218 

Anteversion of the Uterus 234 

Latero version of the Uterus 235 

Retroversion of the Uterus 237 

Anteflexion of the Uterus 237 

Retroversioflexion of the Uterus 241 

Diagnosis of Displacement 246 

Diagnosis of Complications 248 

Diagnosis of Fixation 251 

Torsion of the Uterus 255 

Inversion of the Uterus 256 

Diagnosis of Uterine Myomata 258 

Topography of Myomata 258 

Palpatory Properties of Myomata 262 

Diagnosis of Myoma ....'. 265 

Differential Diagnosis 277 

Diagnosis of Certain Complications 283 

Diagnosis of the Degenerations 288 

Diagnosis of Adenomyomata 292 

Diagnosis of Ovarian Tumors 293 

Diagnosis and Differential Diagnosis of Ovarian Tumors 293 

1. Small Tumors 299 

2. Medium-Sized Tumors ' 305 

3. Large Tumors 312 

Diagnosis of Certain Complications 321 

Diagnosis of the Variety of Ovarian Tumor 328 



CONTENTS xiii 

PAGE 

Diagnosis of Acute and Chronic Oophoritis 333 

Diagnosis of Malignant Diseases of the Uterus 337 

I. Carcinoma of the Uterus 337 

Clinical Pictures and Lines of Extension of Cancer of the Uterus 337 

Diagnosis and Differential Diagnosis of Cancer of the Uterus 344 

Diagnosis of Cancer of the Vaginal Portion 347 

Diagnosis of Cervical Cancer 355 

Diagnosis of Cancer of the Body 357 

Diagnosis of the Extension of Uterine Cancer 359 

Diagnosis of Recurrence 367 

II. Sarcoma of the Uterus 370 

Clinical Pictures and Lines of Extension 370 

Diagnosis and Differential Diagnosis 372 

III. Chorionepithelioma of the Uterus (Syncytioma Malignum) 373 

Neoplasms of the Vagina 377 

Fibromyomata 377 

Carcinoma 377 

Sarcoma 379 

Neoplasms and Ulcerations of the Vulva 380 

Tumors of the Vulva 380 

Ulcerations of the Vulva 385 

Microscopic Diagnosis of Malignant Diseases of the Uterus, Vagina and Vulva , 

(Ruge) 388 

General Portion 388 

Special Portion 401 

Carcinoma of the Vaginal Portion 401 

Carcinoma of the Cervix 409 

Differential Diagnosis 412 

Carcinoma of the Uterine Body 413 

Malignant Syncytioma (Malignant Chorionepithelioma) 421 

Sarcoma of the Uterus 431 

Endothelioma 434 

Malignant Degeneration of the Vagina and Vulva 436 

Microscopic Diagnosis of Polyps and Tissue-Fragments from the Genitalia 

(Myoma, Myosarcoma, Mucous Polyps) 439 

Diagnosis of Tubal Diseases 449 

Salpingitis 449 

Retention Tumors 453 

Diagnosis 458 

Differential Diagnosis 462 

Diagnosis of Certain Special Conditions 465 

Diagnosis of Perforation 468 

Neoplasms of the Fallopian Tubes 469 

Diagnosis of Pelvic Peritonitis 470 

Diffuse Peritonitis 470 

Pelvic Peritonitis 473 

Recent Pelvic Peritonitis 474 

Exudate of Pelvic Peritonitis 475 

Peritonitic Adhesions 479 

Diagnosis of Parametritis 480 

I. Parametritic Exudate 480 

Diagnosis 481 

Differential Diagnosis 486 

Diagnosis of Certain Special Conditions 493 

II. Parametritis Retrahens 498 

Diagnosis of Uterine Catarrh 501 



xiv CONTENTS 

PAGE 

Endometritis 502 

Cervical Catarrh 513 

Colpitis 517 

Vulvitis 519 

Diagnosis of the Extension of tlie Catarrh 521 

Diagnosis of Gonorrhea 522 

Microscopic Diagnosis of Endometritis (Ruge) 526 

Corporeal Endometritis 526 

Cervical Endometritis 542 

Diagnosis of Malformations of the Internal Genitalia 545 

I. "Diagnosis of Imperfect Development of the Uterus and Vagina 546 

II. Diagnosis of the Double Formations of the Uterus and Vagina 551 

Diagnosis of Diseases of the Urinary Appakatus 557 

Preliminary Remarks on Physiology 557 

Diseases of the Urethra 558 

Diseases of the Bladder 563 

Diagnosis of the Causes of Tenesmus Vesicae 563 

Diagnosis of the Causes of Incontinence 572 

Diagnosis of the Causes of Ischuria 577 

Tumors of the Bladder 580 

Vesical Calculi 583 

Foreign Bodies in the Bladder , 585 

Diseases of the Ureter 586 

Diseases of the Kidneys 589 

Diagnosis of Pyelitis 589 

Diagnosis of Renal Tumors 592 

Diagnosis of Movable Kidney 597 

Dystopia of the Kidneys 600 

ANALYTICAL DIAGNOSIS. 

The Causes of Hemorrhage ■ 604 

The Causes of Amenorrhea 615 

The Causes of Dysmenorrhea 621 

The Causes of Sterility 632 

Analytical Diagnosis of Abdominal Tumors 647 

Index. 657 



LIST OF ILLUSTRATIONS 



FIG. PAGE 

1. Examining-chair 6 

2. Examining-room equipped and ready for office work 7 

3. Trimanual percussion of fluid accumulation in the pelvis 8 

4. Trimanual percussion of fluid tumor in the region of the liver and kidney 9 

5. Position of the examiner at the examining-chair 16 

6. Position of the hands in making a combined examination of the uterus 17 

7. Position of the hand in making a combined recto- vaginal examination 19 

8. Ground-glass speculum of Carl Mayer 21 

9. Four ground-glass specula of different sizes 21 

10. Introduction of the ground-glass speculum 21 

11. Simon's speculum (posterior blade) 22 

12. Simon's speculum (anterior blade) 22 

13. Sims' speculum 22 

l-l. Method of introducing the posterior blade of Simon's or Sims' speculum 23 

15. Method of introducing the anterior blade of Simon's or Sims' speculum 24 

16. Bivalve speculum 25 

17. Trivalve speculum 25 

18. Uterine sound 26 

19. Hegar's hard-rubber dilators 35 

20. Metal dilator 35 

21. Metal dilator 35 

22. Laminaria tent armed with a silk ligature 36 

23. Position of the hands in exploration of the uterine cavity 37 

24. Goodell-Ellinger dilator 41 

25. Modified Nitze cystoscope 53 

26. Cystoscope in carbolic acid solution as it should be kept when it is in constant use . . 54 

27. Casper's ureteral cystoscope (newest model) 57 

28. The type of Kelly speculum now most used 59 

29. Dilating the external urethral orifice with the graduated cone dilator 60 

30. Median section, knee-chest posture, showing the relations of the pelvic organs 61 

31. Gonococci in pus 65 

32. Tubercle bacilli in sputum 65 

33. Streptococci in pus 67 

34. Staphylococci in pus 67 

35. Introitus in a nulliparous woman after the first coitus 77 

36. Introitus of a multipara 78 

37. Sagittal section through the pelvis with pelvic axis (curve of Carus) 80 

38. Vaginal portion of a nullipara 81 

39. Vaginal portion of a multipara 81 

40. Median section of the female pelvic organs 82 

41. Showing the uterus with its covering of peritoneum and ligaments, anterior view. . . 83 

42. The same, posterior view 83 

43. Vagina, uterus, right Fallopian tube and ovary S4 

44. Female pelvic organs 86 

45. Ovary and round ligament 87 

46. Female pelvic organs 89 

47. Horizontal section of the pelvis through the middle of the symphysis and the 

third sacral vertebra 90 

XY 



xvi LIST OF ILLUSTRATIONS 

FIG. PAGE 

48. Sagittal section through the pelvis to the left of the uterus 91 

49. Frontal section through the female pelvis 92 

50. Cystoscopic picture of the normal bladder 93 

51. Sigmoid flexure filled with feces 95 

52. Lymphatic apparatus of the female genitalia 96 

53. Arteries^ of the uterus and surrounding structures 97 

54. Veins of the female pelvic organs 99 

55. Vulva of a new-born child 100 

56. Vulva of a woman 100 

57. Frontal section of the genitalia of a new-born child. — Terminal branching of Bar- 

tholin 's glands 101 

58. Terminal branching of Bartholin's glands 102 

59. Urethral mucous membrane, peripheral extremity 103 

60. Bladder of a new-born child at the level of the vaginal portion. — Stratified squa- 

mous epithelium 104 

61. Transverse sections of vagina of a girl fourteen years old, and of a new-born child. . 105 

62. Vaginal portions of a virgin and of a new-born child 106 

63. Vaginal portion of a new-born child with congenital erosion. — Conversion of 

cylindrical into stratified epithelium 108 

64. Epithelium of the uterine mucous membrane and of the cervix 109 

65. Cervical mucous membrane. — Cervical epithelium with basal nuclei 110 

66. Cervical gland (antler-formation) Ill 

67. Cross-section through the corpus uteri of a new-born infant. — Cylindrical epi- 

thelium 112 

68. Uterine glands of new-born infant 113 

69. Normal uterine mucous membrane 114 

70. Uterine mucous membrane 115 

71. Uterine mucous membrane during menstruation, with epithelial hematomata. . . . 116 

72. Musculature of the uterine body 119 

73. Transverse section through the cervix of a new-born child. — Cervical mucous 

membrane 122 

74. Transverse sections of the Fallopian tubes 123 

75. Gravid uterus in the fifth month in marked anteflexion 127 

76. Position of the hands in examining for Hegar's sign of pregnancy 128 

77. Showing implantation of the ovum in the different varieties of pregnancy 144 

78. Left-sided tubal mole (without hematocele-formation) 147 

79. Retro-uterine hematocele in ruptured, left-sided tubal pregnancy 148 

80. Retro-uterine hematocele 149 

81. Distention of the tube with blood, and peritubal hematocele in tubal pregnancy. . . 150 

82. Peritubal hematocele and hemorrhages into the tube in tubal pregnancy 151 

83. Decidua in extra-uterine pregnancy 153 

84. Left-sided intraligamentary tubal pregnancy in the tenth month 160 

85. Right-sided pedunculated tubal pregnancy in the tenth month, with living fetus. . . . 161 

86. Villous trees in various stages of pregnancy 179 

87. Transverse and longitudinal sections of villi (fourth to fifth week) 181 

88. Apex of a villus (fourth to fifth week) 183 

89. Villi at the end of pregnancy 184 

90. Placental remains (after abortion) 186 

91. Villi of hydatid moles 187 

92. Decidua vera 189 

93. Circumscribed changes of the glands in pregnancy 190 

94. Uterine mucous membrane in the ninth month of pregnancy 191 

95. Uterine mucous membrane in the ninth month of pregnancy 192 

96. Decidua vera (third to fourth month) ... 193 

97. Islands of decidual tissue in the uterine mucosa 195 

98. Membranous dysmenorrhea 197 



LIST OF ILLUSTRATIONS xvii 

FIG. PAGE 

99. Decidua vera, showing inflammatory (round-cell) infiltration 198 

100. Ovum from the earliest period 199 

101. Villus from the fourth to the fifth week 201 

102. Position of the internal os between the fourth and fifth months of pregnancy. — 

Beginning Opitz-Gebhard change in a uterine gland 204 

103. Vaginal membrane; epithelium with the tips of papillee 210 

10-4. Retroposition of the uterus from posterior parametritis 214 

105. Dextroposition of the uterus due to a left-sided intraligamentary ovarian tumor . . . 215 

106. Dextroposition of the uterus from right-sided parametritis with adhesions 216 

107. Elevation of the uterus from fixation of the organ after Cissarian section. 217 

108. Anterior and posterior descent of the vagina, with descent of the uterus 220 

109. Anterior vaginal prolapse, with secondary descent of the uterus 221 

110. Primary isolated prolapse of the posterior vaginal wall, with large rectocele 222 

111. Primary descent of the uterus, with inversion of the vagina 223 

112. Total prolapse of vagina and uterus 226 

113. Total prolapse of uterus and vagina, with tuberculous ascites 227 

114. Prolapse of the anterior vaginal wall, with elongation of the cervix 228 

115. Enormous prolapse of the entire vagina, with elongation of the cervix. 229 

116. Cystoscopic picture of small cystocele 232 

117. Cystoscopic picture of cystocele in front of the vulva 232 

118. Anteversion of the uterus 235 

119. Sinistroversion of the uterus 236 

120. Congenital anteflexion of the uterus 239 

121. Anteflexion of the uterus, with fixation 240 

122. Retroversion of the uterus 242 

123. Retroflexion of the uterus 243 

124. Apparent and actual downward displacement of the vaginal portion 244 

125. Position of the tubes and ovaries in anteversion and retroversion of the uterus. . . . 245 

126. Retroposition, retroversion, and retroflexion of the uterus 247 

127. Retroflexion of gravid uterus, with greatly distended bladder 251 

128. Total inversion of the uterus from expulsion of a submucous pedunculated myoma 256 

129. One subserous and two interstitial myomata of the uterus 259 

130. The same in sagittal section .' 260 

131. Interstitial myoma of the posterior wall 261 

132. Submucous myoma in the cavity of the uterine body 262 

133. Submucous myoma in the process of expulsion 263 

134. Submucous myoma expelled and arrested at the external os 263 

135. Subserous cervical myoma 264 

136. Interstitial cervical myoma 265 

137. Submucous cervical myoma (surface view and cross-section) 266 

138. Small interstitial myoma of the anterior wall 267 

139. Large interstitial myoma of the anterior wall 268 

140. Submucous myoma in process of expulsion 269 

141. Subserous myoma of the anterior wall 270 

142. Three subserous myomata of the uterus 271 

143. Intraligamentary myoma of the entire left uterine wall 272 

144. Retroperitoneal myoma of the posterior cervical wall 273 

145. Course of the round ligaments in the various forms of myoma 274' 

146. Course of the adnexa in a cervical myoma 275 

147. Shape of the uterine cavity in subserous, interstitial, and submucous myoma 276 

148. Cystoscopic picture of bladder-floor elevated by myoma in the vagina 287 

149. Cystoscopic picture of a cleft bladder in a case of interstitial myoma 287 

150. Bilateral malignant ovarian tumors in situ 294 

151. Relations of the pedicle in a normal ovary and in an ovarian tumor 295 

152. Relations of ovarian tumors to the broad ligament in sagittal section 296 

153. Ovarian cyst and parovarian cyst of the same side 297 



xviii LIST OF ILLUSTRATIONS 

FIG. PAGE 

154. Right-sided cystic ovarian tumor 299 

155. Left-sided ovarian tumor 300 

156. Retro-uterine ovarian tumor 304 

157. Position of the hands in palpating the pedicle of an ovarian tumor 306 

158. Right-sided parovarian cyst 311 

159. Multilocular ovarian cystoma 312 

160. Pancreatic cyst 318 

161. Pancreatic cyst 319 

162. Large splenic tumor showing distinct notches 320 

163. Tumor of the right lobe of the hver 321 

164. Bilateral intraligamentary papillary ovarian tumor 322 

165. Behavior of the folds of Douglas with retro-uterine ovarian tumors 324 

166. Behavior of the folds of Douglas with intraligamentary ovarian tumors '. . . . 324 

167. Follicular cyst of the ovary 329 

168. Tubo-ovarian cyst 330 

169. Corpus luteum cyst 331 

170. Cystadenoma pseudomucinosum 332 

171. Cystadenoma serosum 332 

172. Primary ovarian carcinoma 333 

173. Dermoid cyst of the ovary 334 

174. Ovarian fibroma 335 

175. Fibrosarcoma of the ovary 335 

176. Normal uterus, showing the different segments of the mucous membrane 337 

177. Cauliflower cancer of the vaginal portion, amputated above the vagina 338 

178. Pedunculated cauliflower cancer of the vaginal portion 338 

179. Infiltrating carcinoma of the vaginal portion 339 

180. Carcinomatous cavity in the vaginal portion 339 

181. Carcinomatous ulcer 340 

182. Infiltrating carcinoma of the cervix 341 

183. Carcinomatous cavity in the cervix 341 

184. Ulcerating carcinoma in the mucous membrane of the cervix 342 

185. Ulcerating cervical carcinoma, with metastasis in the body 342 

186. Diffuse carcinoma of the uterine body • ■; 343 

187. Circumscribed carcinoma of the uterine body 343 

188. Circumscribed carcinoma in a small, senile uterine body 344 

189. Polypoid carcinoma of the uterine body 344 

190. Beginning cauliflower cancer on the anterior lip of the vaginal portion 348 

191. Carcinomatous ulceration of the vaginal portion 349 

192. Multiple mucous polyps of the cervix 350 

193. Follicular polyp from the posterior lip of the cervix 350 

194. Papilloma of the vaginal portion in a pregnant woman 351 

195. Erosion with slightly papillary surface 351 

196. Simple ulcer in process of cicatrization 352 

197. Tuberculous ulcer of the vaginal portion 353 

198. Chancroids on the posterior lip of the cervix and anterior vaginal wall 354 

199. Syphilitic primary sore on the anterior lip of the cervix 355 

200. Condylomata lata of the vaginal portion 355 

201. Vesical mucous membrane in contact with a carcinoma 361 

202. Bladder invaded by a cervical carcinoma 361 

203. Advanced carcinoma of the cervix involving the parametrium 363 

204. Carcinoma of the cervix and of the entire left parametrium 364 

205. Local recurrence in the right parametrium after extirpation of the uterus 368 

206. Recurrence in the parametrium after supravaginal amputation of the cervix 369 

207. Glandular recurrence after total extirpation of the uterus 369 

208. Racemose sarcoma of the cervix 370 

209. Mucous membrane sarcoma of the uterine body 371 



LIST OF ILLUSTRATIONS xix 

FIG. PAGE 

210. Myosarcoma of the uterine body 372 

211. Chorionepithelioma of the posterior uterine wall 374 

212. Vaginal metastasis in chorionepithelioma of the uterus 375 

213. Fibroma of the anterior vaginal wall 377 

214. Pendulous fibroma of the left labium majus 381 

215. Acuminate condylomata of the vulva 382 

216. Elephantiasis vulvae 383 

217. Elephantiasis vulva; 384 

218. Abscess and edema in the vulva 385 

219. Method by which carcinoma spreads to the surrounding tissue 391 

220. Epithelial origin and growth of carcinoma 392 

221. Squamous epithelium scaling off like varnish 393 

222. Solid cancer plugs of various shapes 394 

223. Cancer plug suggesting a gland 394 

224. Cancerous plug containing several epithelial pearly bodies 395 

225. A solid alveolar cancer 395 

226. Growth of solid cancer plugs from cylindrical epithelium 396 

227. Cancer plug of primarily glandular structure 397 

228. Carcinoma in a state of partial myxomatous degeneration 397 

229. Conversion of cylindrical into stratified epithelium 397 

230. Conversion of cylindrical into stratified epithelium 397 

231. Conversion of cylindrical into stratified epithelium 398 

232. Stratified epithelium covering the mucous membrane and sending down plugs .... 399 

233. Horny cancer, cancroid 400 

234. Cross-section of a normal gland. — Proliferating epithelium 400 

235. Fenestra-formation from epithelial proliferation 401 

236. Partial cancerous change of several adjacent glands 402 

237. Apparent two-layer arrangement of epithelial cells 402 

238. Conversion of epithelium of erosions into stratified epithelium . . . 403 

239. Conversion of papillary erosion into a malignant adenoma 404 

240. Peculiar form of adenocarcinoma of the vaginal portion 405 

241. Papilloma of the vaginal portion 406 

242. Conversion of cervical into stratified epithelium 409 

243. Malignant adenoma of the cervix (simple cylindrical epithelium) 410 

244. Malignant adenoma of the cervix (stratified cylindrical epithelium) 411 

245. Malignant adenoma of the cervix (uniformly stratified epithelium) 411 

246. Glandular hyperplasia of the cervix 412 

247. Genesis of inverting malignant adenoma of the body (longitudinal section) 416 

248. Genesis of inverting malignant adenoma of the body (transverse section) 416 

249. Cross-section from an everting malignant adenoma of the body 417 

250. Genesis of everting malignant adenoma of the body (longitudinal section) 417 

251. Genesis of everting malignant adenoma of the body (cross-section) 418 

252. Longitudinal section of an everting malignant adenoma of the body 418 

253. Everting malignant adenoma. 419 

254. Two uterine glands in process of malignant degeneration 420 

255. Malignant adenoma, under high magnification 420 

256. Malignant syncytioma 424 

257. Malignant syncytioma from large tumor of the uterine wall 425 

258. Alterations of pregnancy in the uterine glands 427 

259. Peculiar glandular change 430 

260. Salpingitis 431 

261. Large-cell sarcoma 432 

262. Spindle-cell sarcoma. 432 

263. Lymph-cell sarcoma 433 

264. Periglandular endometritis. Sarcomatous degeneration 434 

265. Endothelioma of the uterine body 435 



XX LIST OF ILLUSTRATIONS 

FIG. PAGE 

266. Glandular endothelioma 436 

267. Hidroadenoma subcutaneum 437 

268. Hidroadenoma polyposum 437 

269. Hidroadenoma fungosum 438 

270. Fragments from the bladder (papilloma) 445 

271. Fallopian tube: single layer of cylindrical epithelium 446 

272. Ureter: stratified epithelium 446 

273. Vermiform appendix: fecal remains, glands, follicles 446 

274. Nasal polyp 447 

275. Catarrhal salpingitis 451 

276. Purulent salpingitis 451 

277. Double pyosalpinx in retroversion of the uterus 452 

278. Various forms of retention tumors of the Fallopian tube 453 

279. Hydrosalpinx with ovary 454 

280. Hydrosalpinx with saccular dilatation of the abdominal extremity 454 

281. Intraligamentary hydrosalpinx of the right side 455 

282. The same in cross-section 456 

283. Right-sided pyosalpinx 457 

284. Left-sided pyosalpinx 458 

285. Right-sided hydrosalpinx 459 

286. Fundus of uterus with bilateral purulent salpingitis 461 

287. Pelvic exudate 475 

288. The same in cross-section 476 

289. Parametritic exudate in the left posterior quadrant 481 

290. Parametritic exudate in the rectovaginal septum 482 

291. Puerperal intraligamentary exudate 483 

292. Parametritic exudate in the left anterior quadrant and anterior parametrium 484 

293. Parametritic exudate in the right broad ligament and anterior parametrium 484 

294. Parametritic exudate occupying the left broad ligament and iliac bone 485 

295. The same in cross-section 485 

296. Hematoma in the right broad ligament 489 

297. Paratyphlitic exudate 490 

298. Intraligamentary parametritic exudate in process of absorption 493 

299. Mucous membrane of the bladder in rupture of an exudate 497 

300. Cystoscopic picture of an exudate that has ruptured into the bladder 497 

301. Parametritis retrahens 498 

302. Schultze's (diagnostic) tampon 504 

303. Uterine glands, normal and forced apart by cellular multiplication 526 

304. Acute interstitial endometritis 527 

305. Chronic interstitial endometritis 527 

306. Interstitial exudative endometritis ■ 527 

307. Combination of periglandular with exudative endometritis 528 

308. Diagrammatic: conversion of stroma cells 528 

309. Stroma cells in dysmenorrheic membranes (decidual change) 529 

310. Multiplication of the glandular epithelium 529 

311. Result of cellular multiplication 530 

312. Result of cellular multiplication 530 

313. Result of proliferation of glandular epithelium (tortuosity) 531 

314. Result of proliferation of glandular epithelium (saw-tooth formation) 531 

315. Result of proliferation of glandular epithelium (hyperplasia) 532 

316. Endometritis glandularis hyperplastica 532 

317. Combination of glandular and interstitial endometritis 533 

318. Formation of ectasise in endometritis .' 534 

319. Endometritis ectatica chronica.. .' 535 

320. Apparent stratification of the epithelium 535 

321. Oblique section through the fundus of a uterine gland 540 



LIST OF ILLUSTRATIONS xxi 

FIG. PAGE 

322. Glands with papillary projections 541 

323. Tuberculous endometritis 542 

324. Follicular erosion (ovula Nabothi) 543 

325. Papillary erosion 544 

326. Uterus rudimentarius bipartitus 548 

327. Pseudohermaphroditismus masculinus externus 550 

328. Uterus bicornis infrasLmplex 553 

329. Uterus bicornis and vagina septa, with occlusion of the right vagina 555 

330. Casper's endoscope for the female urethra 559 

331. Cystoscopic pictures in vesical catarrh 568 

332. Cystoscopic picture in cystitis trigoni 569 

333. Tubercles on the vesical mucous membrane 569 

334. Cystoscopic picture in a case of traumatic fistula in the trigonum 574 

335. Cystoscopic picture of a papilloma of the bladder 582 

336. Cystoscopic picture of a carcinoma of the bladder 582 

337. Cystoscopic picture of a phosphatic calculus 584 

338. Uric acid calculus in the bladder 584 

339. Calcium oxalate calculi in the bladder 584 

340. Skiagraph of two vesical calculi 585 

341. Urine separator after Luys 591 

342. Horizontal section through the abdominal cavity in the region of the kidneys 593 

343. Horizontal section through a renal tumor in situ 594 

344. Renal tumor of the right side 595 

345. Right-sided renal tumor 597 

346. Right-sided movable kidney in the left lateral position 598 



TEXT-BOOK 



OF 



GYNECOLOGICAL 
DIAGNOSIS 



General Diagnosis. 

The purpose of a gynecological examination is to determine the 
condition of the female genitalia and adjacent organs. 

AYe have the following methods at our command: 

External examination; 

Internal examination; 

Combined examination; 

Rectal examination. 

Auxiliary methods of examination are: 

The employment of vaginal specula; 

The uterine sound; 

Dilatation and palpation of the uterine cavity; 

Anatomical (microscopic) diagnosis; 

Cystoscopy; 

Bacteriologic diagnosis; 

Radiography. 



External Examination. 

By means of the external examination of the abdomen changes in 
the genitalia and adjacent structures developing above the pelvic inlet 
are determined. It is employed in cases of large tumors of the uterus 
and ovaries, advanced intra-uterine and extra-uterine pregnancy, ascites, 
diseases of the kidneys, spleen and liver, so-called pseudotumors pro- 
duced by obesity or meteorism, and for the purpose of determining a 
painful area in the abdominal cavity. 

The physician should always begin by making an external examina- 
tion, or he will be in danger of overlooking changes in the upper portion 
of the abdominal cavity, such as high ovarian tumors. 

1 



2 GYNECOLOGICAL DIAGNOSIS 

In making an- external examination the patient should be placed 
on an examining-couch or table, with the trunk slightly elevated and 
the legs drawn up. Usually, the abdomen must be exposed. 

Inspection of the abdomen is employed for the determination 

of certain characteristic changes in shape, such as increased width and 

flatness of the abdomen in cases of freely movable ascites, 

Inspection. • i j t i i 

or the rounded or conical protrudmg abdomen m cases or 
tumor, pregnancy and encapsulated ascites; also for studying changes 
in the skin (striaj, pigmentation, dilated veins) and the umbilicus. 

By inspection of the external genitalia we determine changes in 
the pubes, perineum and lower portion of the vaginal mucous mem- 
brane. As the inspection of the sexual organs offends the woman's 
sense of modesty most, it should be employed only in the .event of disease 
of the external genitalia, or when there is reason to think that the find- 
ings may have an important bearing on the diagnosis of diseases of the 
internal genitalia. The inspection of the external genitalia should be 
made at the end, and not at the beginning of the general examination. 
A glance at the patient's linen may show the quantity and character of 
the discharge or flow of blood that may be present. 

Palpation is the most important part of the external examina- 
tion. The examiner places both hands flat on the abdomen and, while 
making uniform pressure, seeks to determine the contents of the 

abdominal cavity, chiefly with the aid of his finger tips. 

The hands must be warm and dry, and only moderate 
pressure must be made. Palpation consists principally in determining 
differences in consistency between tumors that are more or less hard 
and the surrounding intestines. The greater this difference, as for 
example in the case of a hard myoma, the easier it is to feel the tumor 
and to determine its boundaries; the smaller the difference, as for ex- 
ample in the case of the gravid uterus, the greater will be the difficulty 
experienced in palpation. By means of palpation the shape, mobility 
and contents of tumors are recognized. When the examination is made 
for the purpose of determining a painful area in the abdomen, very 
gentle pressure must be used in order not to be misled by pain due to 
the pressure itself; the boundaries of the painful area are accurately 
mapped out with the finger tips. The relaxation of the abdominal walls 
necessary for satisfactory palpation is best secured by elevating the 
trunk and having the patient draw up both knees; if the intestines 
are distended with fecal matter they must first be emptied by a 
laxative. In examining tumors situated in one side of the abdomen 
the patient should be made to lie on the opposite side. In this po- 
sition the intestines gravitate to the bottom and permit direct palpation 
of the tumor. 



METHODS OF EXAMINATION 3 

Percussion is employed as an auxiliary to palpation when the 
abdominal walls are so thick and tense that they resist the pressure of 
the examiner's hands, or the tumors are so relaxed that their outlines 
cannot be determined by palpation. Percussion is indis- 
pensable in the demonstration of free fluid in the abdomen 
(ascites, blood, pus). Percussion is principally employed to distinguish 
between the tympanitic note obtained over the stomach and intestines 
and the dull sound over a tumor or accumulation of fluid. All tumors 
in close contact with the abdominal walls, whether solid or cystic, are 
dull on percussion; in exceptional cases the note is tympanitic from the 
presence of gases of decomposition; as, for example, in an extra-uterine 
pregnancy sac, hydronephrosis, ovarian tumors. A modified tympanitic 
percussion note is obtained in the case of tumors with adherent intes- 
tines, small collections of fluid between the intestines, and inflammatory 
and carcinomatous tumors situated among coils of intestine. 

It is best to percuss along a line perpendicular to the supposed 
boundary, which usually runs in a circle around the umbilicus, as most 
large tumors are spherical in shape and situated in the median line, and 
the surface of the fluid in ascites is usually parallel to the horizontal 
plane. We begin at the highest point of the abdomen because at this 
point we always expect to find dulness in the presence of tumors, and 
resonance (tympany) if there is ascites. Percussion is then continued 
upward toward the xiphoid process, downward toward the symphysis, 
to each side toward the region of the kidneys and, if necessary, along 
intermediate radii. Percussion should be light in order to exclude the 
intestinal tympany, which tends to obscure the outlines obtained by 
percussion. As a rule, in the case of tumors, the outlines obtained by 
percussion and palpation should coincide. 

Auscultation, in gynecology, is practically employed only in 
the diagnosis and differential diagnosis of pregnancy, for the purpose 
of demonstrating fetal movements, the fetal heart sounds, 
and the uterine bruit. The remaining auscultatory phe- 
nomena, such as intestinal noises, uterine and arterial sounds, have 
little or no bearing on gynecological diagnosis. A stethoscope with a 
large bell is to be preferred on account of the ease and rapidity with 
which the various sound phenomena can be located. 

Internal Examination. 

Internal examination is performed with the finger introduced into 
the vagina and is employed to determine alterations in the vagina 
and portio vaginalis. Occasionally it is possible to palpate, more or 
less indistinctly, tumors lying upon the vaginal vault, which originate 
either in the supravaginal portion of the cervix or in the parametrium. 



4 GYNECOLOGICAL DIAGNOSIS 

or in Douglas's space. Whether or not it is possible to determine the 
character and outlines of such tumors with the accuracy required for a 
positive diagnosis will depend on the degree of resistance of the vaginal wall. 
At the present day the internal examination forms 
merely -a part of the combined examination, i.e., as soon as 
the condition of the vagina has been determined, the external hand is 
placed on the abdomen for the purpose of investigating, by bimanual 
palpation, all the organs situated above the vaginal vault. In those 
cases in which the resistance of the abdominal walls is so great as to 
render the combined palpation absolutely impossible, as, for example, in 
many cases of retroflexion, the internal examination is the only method 
of palpation at our disposal and in such cases is extremely valuable. 

Combined Examination. 

In its narrow sense the combined examination means palpation of 
the internal genitalia through the vagina and through the abdominal 
walls; in its broader sense it includes also a combined examination 
through rectum and abdominal walls, and through rectum and vagina. 

Combined examination through vagina and abdominal walls con- 
stitutes gynecological examination proper and forms the basis of gyne- 
cological diagnosis. Combined examination is very difficult to learn 
and to the beginner seems like an impenetrable mystery; but once it 
has been mastered, the method enables the examiner to make palpatory 
diagnostications with almost incredible accuracy. Such skill, however, 
can only be acquired by assiduous study and retained by constant 
practice. A thorough touch-course and constant training in private 
practice are both equally indispensable. 

For the successful performance of a combined examination the 
following points are important: 

Position of Patient. In making a gynecological examination it 
is important that the patient's position be comfortable and decent, 
and such as to permit as accurate palpation of the pelvic organs as 
Position of possible. These two requirements cannot always be satis- 

Patient. gg^| g^^ -j^j^g same time and to the same degree. If we pay 

proper attention to decency, the patient's position is not suitable for a 
successful examination. The greatest difficulty experienced in the com- 
bined examination is the tension of the abdominal muscles. In order 
to bring about a relaxation of the abdominal walls, the insertions of 
the muscles, i.e., the lower border of the thorax and the upper border 
of the pelvis, must be approximated as much as possible. Hence the 
patient should be placed in such a position that the trunk is flexed on 
the anterior plane, which may be effected by elevating both the trunk 
and the pelvis (dorso-coccygeal position). The trunk should be raised 



METHODS OF EXAMINATION 5 

on a bed-rest or pillows, the head being firmly supported because con- 
traction of the muscles supporting the head causes tension of the abdom- 
inal walls. Approximation of the upper rim of the pelvis is obtained 
by flexing the thighs at the hip-joint. The closer they are brought to 
the body, the greater will be the elevation of the pelvis and, therefore, 
the more thorough the relaxation of the abdominal walls; but it is this 
very elevation of the legs that renders the position indecent, hence 
complete elevation is possible only under full anesthesia. 

The above principles must be observed in the construction of the 
examining-table. If the examination is to be made at the patient's 
home, the examiner must make his choice between the bed and a lounge. 
The physician sits on the edge of the bed or couch and makes his ex- 
amination while the woman, whose body has been raised to an angle of 
about 45 degrees, flexes her thighs on the abdomen, so that the legs 
are approximately vertical and in marked abduction. The position is 
comfortable for both physician and patient and permits a thorough 
palpation of the internal genital organs. A more accurate examination 
can, however; be made by placing the patient crosswise on the bed, 
with the trunk moderately elevated and the coccyx on the edge of the 
bed, the legs being at the same time strongly flexed in abduction and 
held by two other persons or supported on two chairs. The examiner is 
seated on a chair between the woman's legs. As this position is dis- 
tressing to the patient, it should be employed only in cases of necessity 
and especially when a general anesthetic is given. 

[Several gynecological chairs and tables are on the market in the 
United States, all of which have special advantages along with disad- 
vantages. The consensus of opinion among gynecologists is against 
mechanical chairs. They are too cumbersome and possess little advan- 
tage over a small examining-table. The latter should be so constructed 
that it can be dismantled at the end of an office hour and converted into 
a small, sightly table. Every physician should endeavor so to order his 
office that all objects are concealed that may offend or shock his patients. 
For this reason, in a private examining-room, instruments should 
never be in view even when in use, for to patients who may be very 
nervous, the mere sight of a speculum may be sufficient to engender 
hysterical manifestations, or at least so to agitate them that the exam- 
ination is at best most unsatisfactory. Therefore, in selecting an 
examining-table, that one which is the simplest and most free from 
obvious mechanical arrangements is preferable. — Editor.] 

The same careful attention should be paid to decency and to the 
patient's comfort when gynecological patients are examined in the 
office. The examining-couch unquestionably satisfies these two require- 
ments better than anything else: it permits external examination in 



GYNECOLOGICAL DIAGNOSIS 



the most satisfactory manner and, by elevating the trunk and having 
the patient draw the legs up, it is possible in most cases to make a 
sufficiently accurate combined examination. The external genitalia 
can be inspected, the sound can be introduced, glass specula employed, 
massage performed, and the parts cauterized, etc. In general, there- 
fore, the use of the examining-couch is to be recommended : but it does 
not suffice in every case. If extreme elevation of the legs' or even of the 
pelvis is necessary for the purpose of thoroughly relaxing the abdominal 
walls, if examination on the couch has not given a trustworthy result, or 
if a Simon or Sims speculum is to be introduced, the patient must be 




Fig. 1. — ExAMiNiNG-CHAiR. (Original.) 

placed on an examining-chair. The position on the chair is the same as 
that described above when the woman is placed crosswise on the bed, 
and unquestionably permits more accurate palpation of the internal 
genitalia. The only bar to its general employment is the objectionable 
position. Veit-Schroder's chair is the best for practical purposes, and by 
suitable upholstering and a judicious use of covers much can be done 
to make it look less formidable. As it does not permit of the horizontal 
position, however, part of the examination must be made on the couch. 
For this reason a chair with a movable back and leg-supports (Fig. 1), 
so that the patient's position can easily be changed from the vertical 
to the horizontal, is more suitable for a small consulting room. Ex- 
a'mining-chairs provided with ratchets and other mechanical appliances 



METHODS OF EXAMINATION 7 

for bringing the patient suddenly into the desired position are not 
to be recommended, as they only frighten and agitate the patient. 
[In the abdominal tumors of women, the combination of 

'- .... Inmanual 

touch and palpation in the bimanual pelvic examination is Method 

. . . of Percus: ion. 

by far the most eihcient means of diagnosis at our command. 

The tactile sense, naturally, becomes more and more acute with 
increasing experience, so that structures which to the novice are un- 




FiG. 2. — ExAMiNiNG-ROOM EQUIPPED AND Ready FOR OFFICE WoRK. The table is uncomplicated 
and has no obtrusive mechanism to frighten a nervous patient. AU instruments are kept in close touch with 
the examiner but are concealed by a sterile towel. 

recognizable may easily be outlined when a sufficient tactus eruditus is 
acquired. In my own experience the chief difficulty in the differential 
diagnosis in obscure cases has been in judging the "consistence of a 
tumor or encapsulated mass as to whether it was fluid or solid. This 
differentiation is of vital importance in many cases. Thus, for instance, 
an adherent soft intraligamentary myoma, associated with inflammatory 



8 



GYNECOLOGICAL DIAGNOSIS 



disease of the appendages, may closely simulate a pelvic abscess. In 
fact, even in skilled hands, a vaginal incision or puncture may be made 
into a soft tumor mass in the thought that it is encapsulated pus. Sim- 
ilar errors in diagnosis may frequently occur in other parts of the abdo- 
men. Thus a tense hydro- or pyosalpinx may be mistaken for a solid 
tumor; a distended gall-bladder for a tumor of the liver or kidney; a 
deep-seated collection of pus about the appendix for a tumor of the 
cecum or omentum. These mistakes may, in some instances, be un- 
avoidable, notwithstanding the greatest refinement in physical diagnosis. 




Fig. 3. — Trimanual Percussion of Fluid Accumulation in the Pelvis. The vaginal index finger 
makes deep indentation in the vaginal vault posterior to tne cervix, counter-pressure being made by the 
abdominal hand pressing down against the tumor mass, thus collapsing or displacing the intestine, while the 
assistant lightly percusses the tip of these fingers. 

For the detection of fluid, in these obscure cases, I have employed 
for several years a trimanual method of percussion, which has, in 
several cases, proved of signal value, at once clearing up an otherwise 
doubtful diagnosis. This method was first employed as a means of 
differentiation between fluid and solid pelvic tumors. On bimanual 
examination of a pelvic mass of questionable consistence, the intestines 
intervening between the anterior abdominal wall and the tumor may 
dissipate the percussion impulse of the abdominal hand, and although 
fluid may be present, a wave of sufficient intensity to be felt by the 
vaginal touch is- not induced. To overcome this difficulty the tumor 
mass should be confined as closely as possible between the two examin- 
ing hands, while the percussion is made by an assistant. With light, 
quick taps, even small collections of fluid may be detected by the quick, 



METHODS OF EXAMINATION 9 

responsive, pulsatile wave passing from the abdominal to the pelvic 
hand (Fig. 3). Since proving the value of this method in pelvic examina- 
tions, I have systematically employed it in the differential diagnosis 
of abdominal tumors. In this way an adherent and distended gall- 
bladder may accurately be diagnosticated, one hand pressing deeply in 
over the hypochondrium, while with the other deep counter-pressure is 
made just below the fixed ribs (Fig. 4). If fluid is present, light per- 
cussion over the upper hand will give an unmistakable wave in many 
instances. In one case this method proved of considerable value in the 
differentiation of an appendical abscess situated beneath the cecum 




Fig. 4. — Trimantjal Percussion of Fluid Tumor in the Region of the Liver and Kidney. 
One hand is sunk deeply into tlie loin, slightly posterior, thus pushing up as far as possible the tumor, while 
the other hand presses downward against the tumor. Percussion is then made by the assistant the same as 
in the pelvic examination. 



and the lower lobe of a downward displaced liver. Only through 
the employment of this method was it possible definitely to recognize 
the deep-lying encapsulated pus, the ordinary percussion wave being 
destroyed by the superimposed liver. I find this method of signal value, 
for it is of great assistance in clearing up doubtful cases which hitherto 
have only been definitely settled by an exploratory incision. — Editor.] 
For special purposes other positions are also required: 
Examination in the Freund (Trendelenburg) position 
(W. A. Freund) permits more accurate examination of the internal 
genitalia because the extreme elevation of the pelvis allows the intes- 
tines, ascitic fluid, and movable tumors, to fall against the diaphragm, 



10 GYNECOLOGICAL DIAGNOSIS 

and frees the genital organs from neighboring structures that interfere 
with palpation. The Trendelenburg position is obtained by elevating 
the patient in the usual way on an operating-table, or 
intheFreund by placing tliB head and shoulders on the floor or couch 
V and having two assistants seize the thighs and elevate 
the pelvis, the examiner standing between the woman's legs. 

Examination in the standing posture is employed only in 
the diagnosis of prolapse, because it enables the examiner to determine 
the degree of displacement Of the vagina and uterus produced by stand- 
ing and by the patient's ordinary occupation. The shape 

Examination in*^ "^ •' iiiri- 

the Standing of a penclulous abdomcn and the degree of relaxation can 
also be determined best when the woman is standing. 
The younger Freund also recommends the position for the bimanual 
palpation of the lateral and posterior walls of the pelvis. The examiner 
sits on a chair, or kneels on one knee, and introduces the finger into 
the vagina underneath the clothing. As the situation is distressing to 
the patient, this method of examination should be avoided as much as 
possible. Combined examination in the standing posture is impossible. 
Sims's (left lateral) position is not adapted for com- 
bined examination; but, on the other hand, it sometimes 
affords a better view of the anterior vaginal wall and portio vaginalis 
through the speculum. 

The knee-chest position has no advantage for mere purposes 
-K- V, of of diagnosis and has become obsolete. It is also one of 

Knee-chest o 

Position. -^j^g most objectionable positions for the patient. It is, 

however, indispensable when Kelly's methods of examining the bladder 
are to be employed. 

In cases presenting unusual difficulties Profanter recommends that the combined 
examination be made in a warm bath. He points out that the folds of the vaginal walls 
are obliterated by the entrance of the water and that the intra-abdominal pressure and 
the tension of the abdominal walls are diminished and in part abolished. The woman is 
placed in a bath-tub filled with warm water, with the sacrum supported on a pillow. 

[It is hardly conceivable that such an extreme resort for an examina- 
tion as this could be of value. In a case requiring such measures it 
would appear preferable to employ some of the minor anesthetics, such 
as nitrous oxide gas or ethyl chloride, if a more profound anesthesia 
were contraindicated. — Editor.] 

Preparation of the Abdomen. Before attempting combined ex- 
amination, the corset must be removed and constricting parts of 
the clothing loosened so that the abdomen shall be free from pressure. 
Preparation of -^ closely fitting corset causes such protrusion and tension 
the Abdomen. Qf -j^j-^g lower zoue of the abdomen that external exam- 
ination is impossible. At the first examination, when an accurate 



METHODS OF EXAMINATION 11 

diagnosis is to be made, removal of the corset must be insisted upon, 
time-consuming though it be; at subsequent examinations it may be 
dispensed with. In the second place the stomach and intestines should 
be as nearly empty as possible. If the examination is made during the 
first hour or two after the principal meal of the day, the results will 
be unsatisfactory on account of the distended condition of the gas- 
tro-intestinal canal, and unpleasant to the patient. Under such cir- 
cumstances it is better to postpone the examination to the next day. 
The morning is the best time for an examination, and the intestines, 
particularly the lower portions, must be neither distended with air nor 
filled with fecal matter. A full rectum renders accurate examination 
practically impossible and calls for the administration of an enema or 
postponement of the examination to the next day. It is not advisable 
to order the bladder to be emptied before the first examination in every 
case, because in most patients the urethra, the bladder, and the urine 
require examination. 

Disinfection of the Hand. The wall of the vagina and vaginal 
portion of the cervix, with which the finger comes in contact during an 
internal examination, are covered with a thick layer of squamous 
epithelium, and infection is hardly possible without a solu- Disinfection of 
tion of continuity in the mucous membrane. The cervix ^^^ ^'^°''- 

and uterus, on the other hand, are covered with a single layer of 
columnar epithelium, which is very apt to be rubbed off by the exam- 
ining finger, freely exposing the absorbent wall. If the uterus 
contains blood and secretions, the epithelium may be removed by 
maceration and thus an opportunity afforded for the inoculation of 
infectious material. 

But even if the finger does not come in contact with the abraded 
surfaces, either produced by examination or already present, it may 
nevertheless deposit micro-organisms in the secretions of the genitalia 
and in this way infect the mucous membrane or a previously existing 
wound. This is particularly true of gonococci. It is, therefore, always 
desirable that the finger be as nearly as possible free from germs for 
every examination; but it is quite impossible for a busy practitioner 
to comply with this requirement. If there is a recent wound in the 
genital organs, as in the case of abortion; if the uterine cavity is to be 
explored in the presence of neoplasms that bleed readily, particularly 
if they are to be operated on later — such as carcinomata, submucous 
myomata or polypi; and in the case of pregnant women, the most 
painstaking disinfection is absolutely necessary. For an ordinary 
examination it is enough to cleanse the hand thoroughly with a brush, 
soap and water. Thorough disinfection consists in cleansing the hands 
with brush, soap and water for five minutes, washing in alcohol for one 



12 GYNECOLOGICAL DIAGNOSIS 

minute, and in bichlorid of murcury three minutes. A more rapid and safer 
method is to protect the examining hand with a sterile rubber glove. 

It is equally important for the examiner to avoid contact of his 
finger with the infectious secretions of the patient, particularly when 
other exapiinations are to be made immediately afterwards. Infection 
may be carried from one patient to another in cases of breaking down 
carcinoma and myoma, gonorrhea or purulent catarrh. Such accidents 
are best avoided by the systematic use of rubber gloves. 

[The custom is becoming more and more prevalent, in this country, 
to employ rubber gloves or rubber finger-cots in all examinations. Cer- 
tainly in all cases where there is a malodorous discharge, such as 
sloughing fibroids, cancer, or abortion, they should invariably be used. 
By having a number of gloves prepared dry, and well dusted on the 
inside with talcum powder, examination can be made most expe- 
ditiously, and with greater satisfaction to both patient and physician; 
for the former appreciates the care which is being observed in the exami- 
nation, while the latter is more certainly using a prophylactic measure 
for his surgical cases. 

Some of the worst operative infections have been attributed to an 
examination of a septic case, with an ungloved hand, shortly before 
the operation. As it is a well-recognized fact that effective sterilization 
of the hands is not possible, it would be best for every physician, and 
certainly every gynecologist and surgeon, to adopt this plan. — Editor.] 

If the parts are small and the vaginal walls dry, the finger must be 
lubricated with a sterile ointment, byrolin or lubricant tubes being most 
convenient for this purpose. A physician who is in the habit of exam- 
ining patients at their homes should carry with him two brushes in a 
box, bichlorid of mercury tablets, and a tube of byrolin or lubricant. 

While it is a matter of indifference which hand is used for internal 
examination, most gynecologists employ the left. The reason probably 
is that the left hand is the weaker and more delicate and better 
adapted for touch, while the stronger right hand is better 
for making pressure from the outside. In this way the 
individual characteristics of each hand are profitably utilized. In 
examining a patient at her home the physician is obliged to use which- 
ever hand is convenient under the circumstances, depending on the 
position of the bed or couch, unless it can be changed so as to permit 
him to use the hand he prefers. For palpation of the adnexa the hand 
corresponding to the side to be examined is to be preferred because it 
"can be more readily adapted to the curve of the pelvis. Nevertheless 
it seems to be better to palpate the right, as well as the left side of the 
pelvis with the left hand, in order to avoid the introduction of the other 
hand, particularly as this is quite easily done if the examiner takes his 



METHODS OF EXAMINATION 13 

stand on the patient's left. Although the preference is to be given to 
one hand in internal examination, the other must nevertheless be 
sufficiently trained to take its place in case of necessity. The examiner 
should by all means cultivate ambidexterity. 

One or Two Fingers? An examination made with the index 
finger alone is unquestionably more agreeable to the patient because 
the introitus is not distended to the same degree as when two fingers 
are used; but, on the other hand, the result of the exami- oneorTwo 
nation is much more satisfactory in the latter case. Owing Fmgers? 

to the extra length of the third (middle) finger, the examiner can feel 
higher up, and the palpating surface of the fingers also is increased. 
Another advantage is that, by spreading the two fingers, two different 
points can be examined at the same time, the dimensions of the body 
(pelvis) can be estimated and compared, and fluctuation can be deter- 
mined. For these reasons a diagnosis based on palpation with two 
fingers is much more certain. I have seen a large number of diagnostic 
errors occur because only one finger was used. Even in a nullipara 
two fingers can be used with such gentleness that the woman does not 
feel them. I use one finger only when the hymen is intact, or the 
introitus is contracted and painful. 

The resistance of the abdominal walls is an obstacle to palpa- 
tion, to overcome which requires skill and repose on the part of the 
woman, and endless patience on the part of the physician. In rare 
cases the resistance is caused by obesity or edema, con- 

. . Resistance of 

traction oi the muscles, or extreme tension oi the abdominal Abdominal 

Walls 

walls due to large tumors or ascites. Much more frequently 
the resistance encountered is owing to the patient's inability to relax 
her abdominal walls from fear and excitement, modesty, or dread of 
pain, which make it impossible for her to become sufficiently calm. 
The obstacle is therefore best overcome by reassuring the patient. A 
quiet, gentle and reassuring manner on the part of the physician tends 
to quiet the patient, while scolding only makes matters worse; a word 
of encouragement or praise will allay anxiety. Many women do not 
know how to relax the abdominal walls, and when they try to do so 
only add to the rigidity. A good way is to ask the patient to count 
slowly and regularly, and then to breathe with the mouth open, or to 
divert her attention by engaging her in conversation. 

[A very simple and effective expedient, in the editor's experience, 
is to ask the patient to sigh deeply. She does this usually without 
instruction, and if it is repeated, the physician in the meantime 
commending her efforts by telling her how much she is assisting 
him, a very satisfactory examination may be made in an otherwise 
impossible case. — Editor.] 



14 GYNECOLOGICAL DIAGNOSIS 

By laying the hand gently on the abdomen and stroking it, the 
resistance can be overcome in a localized area; or gentle massage may 
be used until the deeper structures are reached with the palpating hand. 
At each expiration the external hand should be pressed in a little more 
deeply, maintaining the ground thus gained during the following inspira- 
tion. In this way the hand gradually gets down to the uterus. In 
spite of every care it will frequently happen that the first examination 
is without result; the second or third examination, however, will gen- 
erally prove more successful, and as soon as the woman has gained 
confidence in the physician and his examination, she will no longer 
present any difficulties. It is unwise at the first examination to persist 
under all circumstances until the correct diagnosis has been made. It is 
much wiser not to frighten and repel the patient by a protracted and 
painful examination. A general idea of the state of affairs should, of 
course, always be obtained at the first visit, and malignant disease 
especially ought to be recognized at once; but aside from that, it is 
better to make a second examination in a day or two, after the woman's, 
abdomen has been properly prepared. The diagnosis will then be made 
much more easily, and will often be quite different from the provi- 
sional diagnosis. This procedure is particularly to be recommended in 
complicated cases. 

Examination under general (chloroform) anesthesia is an excellent 

auxiliary procedure in gynecological examinations. Owing to the 

complete relaxation of the abdomen and the fact that greater 

pressure can be used, the internal genitalia can be very 

Examination '^ . . ' ° -^ 

under Satisfactorily palpated. We need not be so very conserva- 

tive with general anesthesia, which is easily induced in 
women and is usually quite free from danger. In cases of complicated 
tumors occupying the lower abdomen, particularly, a general anesthetic 
is almost indispensable if an accurate diagnosis is to be made. If there 
is any doubt as to whether operation is indicated or not, the diagnosis 
should always be confirmed by an examination under a general anes- 
thetic, otherwise one may be prepared for many unpleasant surprises 
at the operating table. Examination under narcosis is of great value 
in the diagnosis of the seat and character of adhesions in cases of retro- 
flexion, especially when massage is to be employed. Without an anes- 
thetic it is often impossible to determine the extent of a carcinoma in 
the tissues surrounding the uterus. On the other hand, one must not 
be too free with chloroform anesthesia; the result that may be expected 
from the examination must be proportionate to the dangers and 
unpleasant after - effects, which are inseparable from the adminis- 
tration of a general anesthetic. There is some danger in using 
too much force in examining under chloroform, as is the tendency 



METHODS OF EXAMINATION 15 

of an inexperienced examiner; inflammations are often made worse 
in this way, and pus-tubes and extra-uterine gestation-sacs may be 
ruptured. 

[In addition to these dangers two cases have come under the 
editor's notice in which a too vigorous palpation through the rec- 
tum has caused a perforation of this viscus, in one case with a fatal 
result. — Editor.] 

By keeping the patient under careful observation and repeating 
the examination under more favorable circumstances, it is often possible 
to dispense with an examination under chloroform. 

[In this country the use of chloroform is not popular because of 
its supposed greater danger. Ether is, therefore, in general use a^ an 
anesthetic for examinations. The more evanescent anesthetics, such as 
ethyl chlorid and nitrous oxid, seldom effect a perfect relaxation; 
besides, the former has had its fatalities. One great and urgent necessity 
for the employment of an anesthetic is in a young unmarried woman. 
It is the editor's teaching to employ always an anesthetic under these 
conditions: first, because it protects the patient against the moral 
shock of this procedure; and second, and even more important, makes 
certain an examination. Rarely is even an expert specialist able to 
ascertain anything of conclusive diagnostic value without this aid. 
Therefore in young women, when the history strongly indicates the 
presence of a lesion which may require operative relief, the best end is 
served when the anesthetic is given with the understanding that, if 
the suspicion is confirmed, the examination will be followed immediately 
by the operation. This applies especially in cases of dysmenorrhea 
in which stenosis or malposition of the uterus are the cause of this 
symptom. — Editor.] 

Technique of Combined Examination. The patient is placed in the 
above-described position, care being taken to see that she does not con- 
tract any one group of muscles or hold fast to the table. The two hands 
should be crossed on the abdomen. The clothing must not 

, , , , , 111 n-ii . Technique of 

be thrown back over the woman s abdomen. The exammer Combined 

seats himself on the left side of the woman and introduces ^^™"i^ 'oi- 
his left hand into the genitalia under cover of the clothing. If the 
woman has been placed on the examining-chair, the physician stands 
between her legs, with his foot on the platform and the elbow of the 
examining hand resting on his thigh (Fig. 5). The left index finger is 
then introduced into the vulva — also underneath the clothing — the 
thumb being used to separate the labia minora, and pressed firmly 
against the perineum; the crooked middle finger is then slowly intro- 
duced into the vagina, avoiding the urinary meatus, which is always 
sensitive. The hand is then rotated so that the volar surface of the fin- 



16 



GYNECOLOGICAL DIAGNOSIS 



gers comes in contact with the anterior vaginal wall. The fourth and fifth 
fingers are either folded into the hand or held under the buttocks, which 
are slightly raised. In aseptic examinations (see above) the genitalia 
must be exposed for the introduction of the fingers, just as in the case 
of a woman in labor. While the conditions within the vagina are being 



i 




Fig. 5. — Position of the Examiner at the Examining-chair. (Original.) 



investigated, the right hand, which must be warm and dry, is slowly 
placed on the abdomen. Combined examination consists in bringing the 
genital organs between the external and the internal hand. The struct- 
ures are slightly elevated by the internal hand so that they can just be 
reached by the other hand through the abdominal wall. With the 
internal hand the anterior wall of the vagina is gently elevated; while 
the external hand, with the finger-tips directed toward the umbilicus, 



METHODS OF EXAMINATION 



17 



slowly forces in the abdominal walls and pushes the intestines aside 
until the genitalia or the internal fingers are felt (Fig. 6). 

A certain order should be observed in examining the genitalia: 
For reasons already mentioned, inspection of the external geni- 
talia is left to the last, except in case of disease of these structures. 
With the fingers that have been introduced into the vagina 
the conditions in that canal are first investigated. The examiner 
determines its calibre, the tone of the walls, whether the mucous 
membrane is smooth and relaxed, and the direction of the canal. 



^**-»^ 




Fig. 6. — Position op the Hands in Making a Combined Examination op the Utertjs. %. (Original.) 



The tips of the fingers are then carried up to the vaginal por- 
tion, where the following points are investigated: The position of the 
vaginal portion, both in the vertical and the lateral plane, its shape and 
form, the character of the external os, the consistency of the tissues 
and degree of relaxation of the mucous membrane, and the degree of 
mo vability in all directions. Finally, the vaginal vault is palpated 
to determine whether its curvature is normal, or whether it is flattened 
or pushed down by tumors from above. 

While these points are ascertained with the internal fingers, the 
external hand is placed on the abdomen and the combined examination 
begun. First the uterus itself; then the left adnexa (ovary, tube, 

2 



18 GYNECOLOGICAL DIAGNOSIS 

and parametrium), and, finally, the same structures on the right side 
of the organ are examined. (For details see pages 85, 88, 90, 91.) 

With regard to the external genitalia, the examiner determines 
chiefly the shape and form of the labia majora and minora, the width 
of the vulva and character of the perineum, and the presence of inflam- 
mation, eruptions, ulcerations, or neoplasms of the external skin. The 
labia are then separated, exposing the vestibule and introitus vaginae 
for the purpose of inspecting the external orifice of the urethra, the 
clitoris, hymen, Bartholin's glands, the mucous membrane of the vesti- 
bule and of the vagina, and any secretions or blood that may be present 
on the external genital organs. 

The combined examination should be made as painless as possible; 
hence, in introducing the fingers, the examiner must be careful not to 
drag in the pubic hairs, and to avoid any rough handling of the anterior 
commissure and urinary meatus, which are always sensitive. The fingers 
should not remain too long in contact with the introitus, and especially 
the clitoris, as this often causes sexual excitement. The movements of 
the internal fingers must be made slowly and very gently. Gentle pressure 
only must be employed in indenting the abdominal walls with the outer 
hand, as excessive or sudden pressure is painful and at once causes con- 
traction of the abdominal muscles, which interferes with the examination. 
Even greater caution is necessary in examining inflamed organs: rough 
handling of such parts, which are often exceedingly painful, makes the 
patient rebellious and may increase the inflammation. If the woman 
experiences a severe pain during the examination, all hope of quieting her 
for that visit is at an end. Patience and forbearance on the part of the 
examiner bring their own reward, for a woman is quick to recognize and 
esteem these qualities. In spite of all this, the examination must be 
completed in as short a time as possible, and to satisfy both these require- 
ments — gentleness and speed — demands much practice and experience. 
A beginner will do better, if the woman's patience has been exhausted, to 
interrupt the examination and repeat it under more favorable conditions. 

Rectal Examination. 
Examination through the rectum becomes necessary when the 
introitus is closed, or greatly contracted by a hymen, or so painful on 
account of catarrh and vaginismus that the finger cannot be introduced. 
Rectal Palpation through the soft and yielding rectal wall gives a 

Examination. nnuch morc positivc result also when the vaginal wall is tense 
and rigid and resists the necessary degree of invagination. Examination 
through the rectum is particularly useful in all cases of disease in the 
posterior portion of the parametrium, the folds of Douglas, Douglas' 
space and the recto-vaginal septum. It is urgently recommended for 



METHODS OF EXAMINATION 



19 



the diagnosis of carcinomatous and inflammatory thickening of the 
parametrium, in the presence of exudates, hematomata or tumors in 
Douglas' space, and of alterations in the posterior uterine wall. One 
finger is enough in cases of disease in the neighborhood of the lower 
portion of the rectum; but in the presence of tumors seated at the level 
of the cervix and higher, it is necessary to introduce two fingers into 
the rectum, which can be done only under general anesthesia. The 
introduction of the entire hand into the rectum, as recommended by 
Simon, is unnecessary and has been given up on account of the danger 
it involves. In examining through the rectum it is best always to intro- 




FiG. 7. — Position of the Hand in Making a Combined Recto-vaginal Examination. ^. (Original.) 

duce the thumb into the vagina at the same time; in this way tumors 
felt through the rectum can be controlled and their topography deter- 
mined with greater accuracy; at the same time a combined exami- 
nation can be made of the posterior portions of the parametrium and 
of the recto-vaginal septum (Fig. 7). 

The rectum must be emptied before attempting a combined recto- 
vaginal examination. One or, if necessary, both fingers are then intro- 
duced with great care so as not to produce a fissure; the two walls of 
the gut which are in apposition are separated, and the fingers are carried 
up through the fold of Kohlrausch to the level of the cervix and pelvic 
connective tissue. If any difficulty is experienced in finding the entrance 



20 GYNECOLOGICAL DIAGNOSIS 

to the upper portion of the rectum, the gut should be moderately filled 
with water (Sellheim). It is not necessary to disinfect the hand for a 
rectal examination, but in order to protect one's fingers from pollution 
a rubber finger-cot should always be worn. The finger should never 
be carried directly from the vagina into the rectum, on account of the 
danger of transferring micro-organisms, especially gonococci, in this way; 
disinfection or the use of a glove is necessary in cases of this kind. 

Examination of the Genitalia tlirough the Bladder is necessary 
only in very exceptional cases in order to determine the position 

of the bladder in relation to tumors and exudates in the 
thToenftaiia ° auterlor parametrium or preperitoneal cavity in immediate 
Bilddw.*'"' contact with the viscus, and especially when operative 

interference is contemplated. Before doing so, one should 
try to obtain the necessary information by introducing a male catheter. 
If the results are still uncertain, the finger must be introduced. For 
this purpose the urethra must be dilated. 

Simon's urethral specula or Hegar's dilators, from the thickness 
of a catheter to that of a finger, are employed. The instruments are 
sterilized by boiling, and slowly and cautiously introduced. Successive 

sizes are used until the necessary dilation has been secured, 

Technique of _ _ . -^ . ' 

Urethral thc fiugcr being introduced immediately after the largest 

Dilatation. . • i i tc • 

mstrument has been withdrawn, it resistance is encoun- 
tered at the external orifice of the urethra, it must be divided on both 
sides a distance of about 0.5 cm. After the examination has been com- 
pleted, the bladder and urethra are irrigated with a 3-per-cent. boric 
acid solution, and the incisions or lacerations at the meatus closed with 
sutures. The palpating finger must be carefully disinfected, because 
dilatation is always attended with slight lacerations. 

By means of examination of the bladder with the cystoscope dis- 
placements and alterations of the vesical wall, caused by tumors in 
close apposition, can be very satisfactorily determined, and the develop- 
ment of cystoscopy practically enables us to dispense with palpation 
of the bladder for this purpose almost entirely. 

Method of Using Specula. 

Specula are used to separate the vaginal walls, and thus make 
possible direct inspection of the vagina, the vaginal portion of the lower 
segment and the cervical canal. They are employed for the purpose 
of recognizing changes limited to the surface of these parts, such as 
discoloration of the mucous membrane during pregnancy, catarrh, 
superficial ulcerations of the vaginal portion, erosions and beginning 
carcinoma; hence they are not needed in every gynecologic examina- 



METHODS OF EXAMINATION 



21 



tion, but only when it is desired to study changes in the mucous 
membrane which cannot be certainly recognized by palpation. 
Gynecologists use two kinds of specula: 





Fig. 8. — Ground-glass Speculum of 
Carl Mayer. (Original.) 



Fig. 9. — Four Ground-glass Specula of Different 
Sizes. (Original.) 



1. The Qround=Qlass Speculum Designed by Carl Mayer. The 

speculum must be perfectly cylindrical and the glass must not be too 
thick, so that the examiner may see as much as possible when the vagina 




Fig. 10. — Introduction of the Ground-glass Speculum. (Orifiinal. i 

is distended. It must not be too long, and the upper end must be 

bevelled so as to bring the vaginal portion well into view when the tube 

is rotated; the anterior border is rolled (Fig. 8). Four sizes 

are usually employed, the diameters of which are about 4, 

3, 2.5, and 1.5 cm., respectively (Fig. 9). No. 2 is generally used for 

multiparas, and No. 3 for nulliparous women. The technique is as 



Ground-glass 
Speculum. 



22 



GYNECOLOGICAL DIAGNOSIS 



follows: The labia majora are separated with the index and middle 
fingers and the left hand applied to the internal surface of the labia 
so as to expose the introitus. The speculum, previously lubricated 
with vaseline or byrolin, is held in the right hand with the anterior 
opening toward the palm, and the index finger applied to the upper 
surface of the speculum near the bevelled edge. The instrument is 
placed flat against the perineum so that the opening is at the level 
of the introitus (Fig. 10), and strong pressure is made on the peri- 
neum while it is slipped into place. Contact 
with the urinary meatus must be avoided. 
If the introitus is narrow, and when there is 

vulvitis or vaginismus, the 
introduction of the specu- 





FiG. 11. — Simon's Speculum (pos- Fig. 12. — Simon's Speculum (an- 
terior blade). Ji. (Original). terior blade). J^. (Original.) 



Fig. 13. — Sims' Speculum. 



lum may be very painful and occasionally attended with the pro- 
duction of minute tears of the mucous membrane. After the speculum 
has been introduced into the vagina it is at once carried up to the 
vaginal portion, the anterior lip of which first enters the bevelled 
end of the speculum, while the external os and the posterior lip remain 
hidden behind it. A beginner thus gets the impression that he is 
dealing with hypertrophy of the anterior lip, but by depressing 
the speculum a view of the posterior lip also can be obtained. When 
the cervix is adherent posteriorly or laterally to the pelvic wall, it is 
often difficult to find the vaginal portion. In such a case we follow 
the lumen of the vagina until some part of the portio vaginalis is dis- 



METHODS OF EXAMINATION 



23 



covered, being recognized by the smooth charac^ter of the mucous 
membrane; the speculum is then strongly depressed and a view of the 
external os is obtained. One must be careful not to push the speculum 
too far up, because by doing so the vaginal vault is displaced upward 
and the separation of the labia produces an artificial ectropion; by 
slightly w^ithdrawing the speculum the vaginal portion can usually be 
brought into view without difficulty. As the examiner withdraws the 
speculum, he alternately raises and depresses the tube in order to get 




Fig. 14. — Method of Introducing the Posterior Blade op Simon's or Sims' Speculum. (Original.) 

a good view of the lateral walls as far back as the introitus. Accurate 
inspection of the vaginal portion with the ground-glass speculum is some- 
times difficult because the cervix is displaced too far upward with this 
instrument and does not receive sufficient illumination. It is therefore 
better to examine with Simon's speculum. The ground-glass speculum is 
very useful in daily practice, because it can be used without an assistant, 
and a variety of therapeutic procedures can be carried out with its use. 
2. Simon's or Sims' Speculum consists of two blades attached to 
handles and is employed for the purpose of separating the two vaginal 



GYNECOLOGICAL DIAGNOSIS 



walls. The view obtained with a Simon or Sims speculum is much 
more satisfactory; the examiner sees the vaginal portion, the entire 
vaginal vault, and the lateral walls of the vagina. The 
vaginal portion, when the uterus is movable, comes well down 
between tlie two blades and can be readily studied under good illumina- 
tion, or drawn down with a double tenaculum for a more careful 



Simon's 
Speculum. 




Fig. 15. — Method of Inteoducing the Anterior Blade of Simon's or Sims' Speculum. (Original.) 

inspection. It is only when the cervix is fixed that inspection is diffi- 
cult, even with Simon's or Sims' speculum. The only obstacle to 
its more general employment is that an assistant is required when 
the examiner needs a free hand for sponging the vaginal portions, 
or other manipulations. 



METHODS OF EXAMINATION 



25 




Fig. 16. — Bivalve Speculum. 



Simon's speculum consists of two blades, one concave for the pos- 
terior (Fig. 11), and one flat for the anterior wall (Fig. 12). A stock of 
several sizes is necessary. (It is important to see that the narrower 
blades are not made shorter, as instrument makers are very apt to do.) 
The blades are attached to handles, 
a straight one for the posterior 
blade and a curved handle for the 
anterior, to correspond with the 
prominence of the symphysis. 

The examiner seats himself be- 
tween the woman's legs, in front of 
the examining-chair, and separates 
the introitus with two fingers of the 
left hand. The posterior blade is 
then taken in the right hand and al- 
lowed to glide slowly into the vagina 
(Fig. 14). The handle is then trans- 
ferred to the left hand, and the peri- 
neum forcibly depressed so that the vulva gapes ; the handle of the an- 
terior blade is then taken in the right hand, placed on the abdomen, and 
the blade allowed to enter immediately below the urinary meatus and 
as far away as possible from the posterior blade (Fig. 15). The two blades 
must not be brought too close together, in order to avoid catching folds 
of mucous membrane between them. In removing the specula, which is 
accomplished in the inverse order, special care is necessary to keep the 
blades well apart. The specula must be boiled every time they are used. 
[The specula most commonly used in the United States are the 
trivalve and bivalve. The trivalve is of especial value, for with slight 
dexterity it may be made to serve almost every end in an ordinary 

examination. By introducing it col- 
lapsed well up to the cervix, then 
gently spreading its blades with a 
set screw, and gently manipulating 
it, the cervix may be brought into 
perfect view. After completing the 
inspection, the instrument is grad- 
ually withdrawn with open blades 
until the outlet is reached, when it 
is again collapsed and withdrawn without pain. As it is withdrawn, all 
parts of the vaginal tract may be inspected. It serves all purposes so well 
that it or the bivalve speculum has very largely supplanted Ferguson's, 
Simon's, and Sims' specula for ordinary office use. For examination 
when the patient is under an anesthetic, the latter instruments are more 




Fig. 17. — Trivalve Speculum. 



26 GYNECOLOGICAL DIAGNOSIS 

generally in vogue. In the editor's experience, the bivalve or trivalve 
speculum suffices for all forms of gynecologic local treatment. — Editor.] 




The Uterine Sound. 

The aiterine sound (Fig. 18) is a probe-like instrument about 30 cm. 

in length, with a broad handle, and marked with ridges on the upper 

side to enable the examiner to recognize the position of the sound in 

the uterus. The tip is armed with a knob-like enlargement about 

2 to 3 mm. thick, in order to avoid injuring the uterine 

wall. The convex side is graduated by means of shallow 

incisions in centimeters, and 7 cm. from the knob is a ring 

the distance of which from the external orifice readily 

enables the examiner to determine whether the sound is 

in the uterine cavity or only in the cervix. The sound 

must be made of flexible metal so that it can be bent to 

correspond to any curve of the uterus. 

Sounding of the uterus must be performed with the 
strictest aseptic precautions. The instrument must be 
boiled before it is used in order to avoid the introduc- 
tion of germs from the vagina into the uterine cavity, 
which is ordinarily sterile. While the micro-organisms 
which inhabit the vagina and cervix are harmless to 
living tissue, they may, in the presence of traumatisms 
and material capable of decomposition, readily produce 
infection. 

The technique of the introduction of a 
sound must therefore be such as to preclude the entrance 
of vaginal germs into the uterus. This is best accom- 
plished by exposing the external os with the speculum. 
For this purpose the simplest is the cylindrical, ground- 
glass speculum [or, as indicated above, the bivalve or 
trivalve speculum. — Ed.], as the examiner can hold it 
himself while introducing the sound; whereas a specu- 
lum of Simon's type requires an assistant. Disinfection of the vagina 
is not absolutely necessary. The vaginal portion is brought into the 
speculum and its surface, particularly the external os, carefully 
cleansed with a cotton pledget saturated in a 1 : 1000 
solution of bichlorid. The sound is then taken in the 
right hand and introduced into the cervical canal until it meets 
with resistance. Holding the sound in this position with one hand, 
the cylindrical speculum is then withdrawn over the sound with the 
other, leaving one hand free (usually the left) two fingers of which are 
applied to the external os. The handle is then depressed, and the sound 




Fig. 18. — Uter- 
ine Sound. 14. 
(Original.) 



Technique. 



METHODS OF EXAMINATION 27 

gradually pushed farther into the uterus until it passes the internal os 
and enters the uterine cavit3^ This is attended by an elevation of the 
uterus through 20 to 30 degrees; hence sounding requires a certain 
degree of mobility of the organ. Quite frequently the sound catches 
in the folds of the cervical mucous membrane or on the internal os; 
this may sometimes be overcome by using a thicker sound. The universal 
remedy, however, when difficulties are encountered in the cervical canal, 
consists in drawing the vaginal portion forward with the double tenac- 
ulum. This smooths out the folds in the mucous membrane and 
obliterates the angle at the internal os, so that the sound readily enters 
the uterine cavity. The double tenaculum may be held with the little 
finger of the left hand so as to dispense with the services of an assistant. 
In abnormal positions of the uterus the technique of introducing 
the sound is somewhat different. In acute-angled anteflexion a sharp 
curve must be given to the sound, and the vaginal portion drawn forward 
with the double tenaculum. In retroversion of the uterus introduction 
of the sound is attended with the least difficulty because the vagina, 
cervical canal and uterine cavity form a straight line; the sound is 
introduced without depressing the handle. In retroflexion of the uterus 
the sound is introduced in the ordinary manner into the cervical canal; 
it is then rotated so that the concavity is directed posteriorly, and allowed 
to glide into the uterine cavity by elevating the handle. For this reason 
the position of the uterus must always be accurately determined before 
using the sound. The most important requisite for successful sounding 
is a light and steady hand. The channel through which the sound is 
to make its way must be found solely by the employment of skill, 
without using any force whatever. 

The contraindications to the use of the sound are: 
1. Pregnancy. The introduction of the sound into the gravid 
uterus often causes injuries of the ovum and abortion. It is true that 
during the first months the sound often enters between the contra- 

ovum and the uterine wall, and no abortion results because indications. 

the irritation of the sound is not sufficient to produce labor pains; but 
if the ovum completely fills the uterus, the procedure is almost invariably 
attended with injury to the ovum, which in most cases is followed by 
abortion. The best way to avoid sounding a gravid uterus is to deter- 
mine beforehand whether the woman is pregnant; or, a still safer rule 
is always to inquire about the last menstruation before introducing 
a uterine sound. The conditions which are most likely to lead to the 
introduction of a sound into a gravid uterus are the occurrence of preg- 
nancy in a woman while she is under gynecologic treatment, and the 
occurrence of pregnancy under conditions which render it extremely 
unlikely, such, for example, as marked degrees of prolapse. It follows 



28 GYNECOLOGICAL DIAGNOSIS 

therefore that the use of the sound for the purpose of making the 
diagnosis of pregnancy is not justifiable. If the physician has been 
so unfortunate as to sound a gravid uterus, the woman should be put 
to bed for a few days, and several doses of opium administered in order 
to prevent abortion. 

2. Acute infection in the neighborhood of the uterus. 
As the introduction of the uterine sound is always attended with a 
forward movement of the cervix and elevation of the uterine body, 
it necessarily exerts traction on exudates connected with these struc- 
tures. In this way we often see exacerbations of parametritis and peri- 
metritis and the occurrence of recent peritonitis in tubal disease. In 
the presence of hematocele and recent tubal pregnancy sounding should 
always be avoided, because traction on such structures may produce 
fresh hemorrhage and sometimes cause necrotic decomposition. In 
chronic inflammations not attended with much pain the cautious use 
of the sound is permissible. For these reasons the tissues surrounding 
the uterus must be subjected to careful examination before resorting 
to the use of a uterine sound. 

3. Virulent catarrh. Sounding the uterus is not permissible 
under these circumstances because carriers of infection, especially gono- 
cocci, are thereby introduced into the uterine cavity; or, if the uterine 
cavity is already diseased, into the tubal orifices; hence the introduction 
of the sound and intra-uterine manipulations generally occupy an im- 
portant place in the etiology of gonorrheal pus-tubes. As a positive 
diagnosis of virulent catarrh cannot always be made, it is wise to avoid the 
use of the sound in the presence of any purulent or suspicious discharge. 

There are other cases in which the use of this instrument is not 
without danger. It may produce an infection, not so much 
through germs attached to the sound itself, as from the fact that in 
spite of every care organisms may be introduced with it 
fiTddent to from the vagina into the uterine cavity and inoculated into 

of'thl'^sound rninute wounds of the mucous membrane; hence the great- 
est care is necessary to avoid any traumatism of the mucous 
membrane, and if the procedure is followed by bleeding, it is better to 
disinfect the uterus. The accident that is dreaded more than any other 
is perforation of the uterus. A slight injury of the mucous membrane 
is by no means uncommon even under the greatest care, but the 
substance of the uterus, if the consistency of the organ is normal, prac- 
tically always resists the entrance of the sound. If the muscle is softened 
by fatty degeneration during the puerperium, or the presence of malig- 
nant growths; if the uterus is atrophied; or if, in the presence of a 
myoma, one wall of the uterus is greatly attenuated, very slight pressure 
often suffices to perforate the uterine wall. Under such circumstances 



METHODS OF EXAMINATION 29 

the sound must be introduced very slowly. As soon as the examiner 
feels that the sound is entering the parenchyma he must withdraw it at 
once. Unfortunately the instrument often passes through the wall 
without the examiner's feeling the slightest resistance, and disappears 
into the vagina up to the handle. Perforation of the uterus with the 
sound is almost always unattended by danger; if, however, the viscus 
contains decomposed material, the accident may be followed by peri- 
tonitis. If perforation occurs, the woman must be kept quiet for a few 
days and treated with small doses of opium. — Hemorrhage of con- 
siderable severity not infrequently occurs during the introduction of 
the uterine sound. It is most likely to occur in cases of proliferative 
endometritis, carcinoma, or subinvolution of the uterus. The hemor- 
rhage may be attended with danger when the uterus contains the remains 
of an abortion or placental masses of considerable quantity. Even 
when the instrument was used with great care, I have often seen 
profuse hemorrhage in these cases, requiring for its complete arrest the 
packing of the cervix or closure of the external os with sutures. For 
this reason the introduction of the sound should be avoided when there 
is reason to suspect that the uterus may contain large remnants of an 
abortion or placental tissue. 

It is evident from what has been said that sounding the uterus 
is by no means a simple operation, and it should therefore be 
used as rarely as possible. It is not a necessary part of 
every gynecologic examination, and should be em- 
ployed only in the presence of a definite indication and 
when the desired result cannot be obtained without 
its use. 

The greater the examiner's skill in palpation, the less will be the 
need of using the sound; it is required chiefly for investigating 
the state of the uterine cavity. [One might say, as a corollary, 
the less the examiner's skill, the greater the danger from 

Indications for 

the use of the sound, and the less information its employ- the use of the 

•n PC 1 mi r -ill ii ii i Uterine Sound. 

ment will anord. Iherefore it should only be used by the 
skilled examiner. — Editor.] By means of the sound we first determine 
the width of the cavity, and this gives us some clue to the degree 
of relaxation of the uterus or distention of the cavity by abnormal con- 
tents. Normally the excursion of the tip of the sound in the uterine 
cavity, when the handle is rotated, is limited; but if the cavity is dilated, 
the sound can readily be moved in all directions and rotated around its 
longitudinal axis. Abnormal contraction of the uterine cavity is recog- 
nized by the fact that the movements of the sound are extremely limited. 
The palpation of intra-uterine tumors is much more difficult 
than one would suppose. Soft polypi with slender pedicles readily avoid 



30 GYNECOLOGICAL DIAGNOSIS 

the sound and escape the examiner's notice. Submucous myomata of 
firm consistency and broad base are somewhat more easily recognized, 
and give the impression of a prominence of the internal uterine wall; 
but even large solid tumors which completely fill the uterine cavity are 
not always recognized with the sound, as I have frequently had occasion 
to observe; hence too much reliance should not be placed on the results 
of sounding in this respect, and if polypi are suspected, the cervical 
canal should be dilated and the uterine cavity explored with the finger. 
The information with regard to the condition of the endometrium 
which is gained by examination with the sound is, on the other hand, 
quite positive. In fact, irregularities of the surface are felt much 
better with the sound than with the finger, and the detection of such 
irregularities is one of the chief uses of the instrument. Normally the 
endometrium feels smooth, or at most presents a few inequalities of 
the surface at the fundus. In carrying the sound from one cornu to 
the other, the centre of the fundus is not infrequently felt as a prominent 
ridge. If distinct irregularities are discovered, they are usually patho- 
logical. They are felt in carcinomatous changes of the mucous mem- 
brane, in chronic fungous endometritis, and retention of small portions 
of decidua after abortion. The detection of these irregularities requires 
some skill in handling the instrument. With the internal fingers applied 
to the vaginal portion, the sound is carried to the fundus, rotated in 
various directions with some pressure, or allowed to glide along the 
uterine walls and angles of the uterus, at the same time moving the 
instrument in various directions. In order to be positive that inequali- 
ties and rough places are present, the tip of the sound must be held 
firmly against the wall. The variety of hypertrophy cannot be posi- 
tively determined by the nature of the inequalities. The presence of 
pain in the endometrium, and its degree, can also be tested with 
the sound. With a healthy endometrium careful sounding is pain- 
less except in the case of sensitive nervous women, who frequently 
complain of pain as the sound passes the internal os. If, in a woman 
whose resistance is good, contact of the sound with the endome- 
trium is painful or even produces spastic conditions of the uterus, the 
existence of inflammation may be suspected. It is sometimes very 
difficult to distinguish perimetritic or parametritic from endometritic 
pain. Perimetritic pain is elicited if the sound in passing the cervix 
pushes it forward and causes traction on inflammatory bands behind 
the uterus; or if the uterine body, which tends to straighten up as the 
sound enters the cavity, pulls on adhesions situated in front. One is 
not justified in diagnosing endometritic sensitiveness except when the 
uterus is completely movable, and careful touching of the endometrium, 
without producing any dislocation of the uterus, elicits pain. It usually 



METHODS OF EXAMINATION 31 

takes the form of a cramp-like pain in the lower abdominal or umbilical 
region. In examining the uterine cavity for inequalities or painful 
points, it is well to follow a certain system: beginning first at the fundus, 
then passing the sound over the anterior and posterior walls, and finally 
in parallel lines over the angles and orifices. By means of the sound 
we also determine occlusions or stenosis in the cervix and in 
the body cavity. A normal orifice readily admits the tip of a sound 
measuring from 2 to 3 mm. in thickness. The mere resistance to the 
introduction of the sound must not, however, be regarded as a sign of 
stenosis, for an inexperienced examiner is apt to catch the sound in 
folds of the cervix. If, however, the sound is readily arrested at the 
same point while the cervix is drawn down with the tenaculum, or if 
the examiner receives the impression that the sound passes with diffi- 
culty a certain point, the presence of a stenosis may be suspected. 
Stenosis in the uterine cavity is much more rare and also gives the 
impression of an obstacle to the advance of the sound. 

Finally, the introduction of the sound is useful as affording a means 
of confirming the diagnosis of uterine diseases which lead to short- 
ening, lengthening or displacements of the organ. In general 
these conditions are detected by palpation, but the results of palpation 
are not always as positive as one might wish. In such a case the find- 
ings may be supplemented by means of the uterine sound. In the first 
place the instrument may be used to find the uterus, if it cannot 
be felt on account of the thickness of the abdominal walls, or if the 
organ is hidden between tumors and cannot be palpated on that account. 
The sound is introduced, and by noting the direction which it takes 
the position of the uterus may be inferred; or the tip of the sound 
within the uterine cavity may be located through the abdominal wall 
and thus the position of the fundus determined directly. In these cases 
special care is necessary in handling the sound because the direction 
of the uterine cavity is not known, and the danger of injuring the wall 
is therefore increased. 

Case 1. In looking for the uterus in a case of intraligamentary cystic tumor, I once had 
the ill luck to perforate the attenuated wall of the viscus and pass the sound into the tumor. 

There is no doubt that in the great majority of cases in which the 
sound is employed, it is introduced for the purpose of measuring 
the uterine cavity and in that way determining the size of the 
uterus. By means of careful palpation, diminution or enlargement of 
the uterus can be recognized without difficulty, but owing to the variable 
thickness of the wall the interpretation of our findings is often quite 
unreliable. A comparison of the results of palpation with the measure- 
ment obtained with the sound often offers the best means of determining 



32 GYNECOLOGICAL DIAGNOSIS 

the length of the uterus and the thickness of its walls. This method is 
employed particularly in the case of myomata, in chronic metritis and in 
atrophic conditions. The thickness of the uterine wall can 
readily be determined by palpating the sound as it lies in the uterus 
through ,the abdominal wall. In this way small myomata in the uterine 
wall can readily be recognized. In rare cases the use of the sound is jus- 
tified for the purpose of detecting adhesions_ around a retro- 
flexed uterus. The sound is introduced into the retro flexed uterus, 
turned on its axis, and the handle depressed for the purpose of elevating 
the uterus. If the organ is movable it readily follows the movement 
of the sound. In the presence of adhesions an inelastic resistance is 
encountered, and the procedure causes pain. This method also is 
employed only when palpation has failed to give results. 

The information obtained by means of the sound usually has to 
do with the finer points in the diagnosis, such as are expected only from 
a specialist; hence the ordinary practitioner very rarely has occasion 
to use the sound, and he should never resort to its use merely for the 
purpose of supplementing the results of palpation when these have 
proved inadequate. 

[The author has very fully warned against the employment of this 
instrument. It carries with its use so much danger that it should only 
be employed by an expert, and even he would be severely censured by 
his colleagues should an accidental infection occur. The rule, there- 
fore, may well be laid down, that a sound is only to be used in cases 
of the very gravest doubt and then only under the most extreme pre- 
caution. The editor has so frequently seen such serious results follow 
the careless introduction of a sound that he believes it should be 
only an instrument of an expert's armamentarium. — Editor.] 

Dilatation and Palpation of the Interior of the Uterus. 

We have several methods at our command for the diagnosis of 
intra-uterine diseases, — sounding of the uterine cavity, the microscopic 
examination of tissue obtained by curettage, and palpation of the 
interior of the uterus with the finger. There is no doubt that the sense 
of touch is most delicate with the sound, and inequalities and roughness 
of the uterine wall can be detected without difficulty by its aid. The 
finger is best adapted for recognizing circumscribed gross changes, such 
as polypi, myomata, or carcinomatous infiltration; while the micro- 
scope enables us to recognize with certainty the histologic changes 
due to superficial disease processes. A cancer of the body of the uterus 
can at best only be suspected when marked irregularities in the uterus 
are felt with the sound. The diagnosis becomes certain only when 
particles of the proliferated tissue, removed with the curette, are exam- 



METHODS OF EXAMINATION 33 

inecl under the microscope and the histologic structure of carcinoma is 
demonstrated; but cancer of the body as well as cancer of the cervix 
may be diagnosed with equal certainty if the finger ig introduced and 
infiltration or ulceration is felt in the wall of the body. In the case of 
sarcomata and polypi the diagnosis is arrived at in a similar manner. 
The two methods, internal palpation of the uterus and microscopic 
diagnosis, are, therefore, in a certain sense consonant -procedures. The 
same end may be reached by either, and the choice between the two 
will frequently depend on the physician's personal preference. Aside 
from the fact that dilatation of the cervix followed by internal palpa- 
tion of the uterus is unquestionably more dangerous than exploratory 
curettage, it must be emphasized that the use of the microscope is 
unquestionably superior to internal palpation of the uterine body, 
because there are many sources of error when the latter procedure is 
employed. In the first place, the constriction exerted by the cervix 
on the finger impairs its sense of touch, and its movements are so 
restricted within the narrow uterine cavity that the results of palpation 
are much less positive. But even aside from these external difficulties, 
the sensation of touch is not sufficiently delicate to detect cancer of the 
mucous membrane in its earliest stages, before the process has gone on 
to infiltration and distinct ulceration; whereas microscopic examina- 
tion yields a positive result even at this stage. Again, it is very diffi- 
cult to distinguish between sarcomatous and benign uterine polyps by 
the sense of touch alone. The attempt to diagnose malignant disease 
of the uterus by means of the palpating finger alone is associated with 
so many sources of error that mistakes are bound to occur very fre- 
quently. Microscopic diagnosis also has its limitations. It may happen 
that the curette does not bring away any of the diseased tissue, although 
this is rare; a circumscribed neoplasm may begin to develop at a point 
in the uterine cavity which is difficult of access; or the histologic 
picture may not be sufficiently clear. For these reasons it must be 
conceded that both methods have their value, although microscopic 
diagnosis is by far the most important. The procedure to be adopted 
in the case of hemorrhage should be as follows: First, the uterine 
sound is employed, and if inequalities are discovered, the uterus is 
curetted and the scrapings subjected to a microscopic examination. If 
this also fails to give the desired result, the examiner should proceed 
to palpate the interior of the uterus. 

Case 2. In 1895 I performed a curettage on an elderly woman on account of 
profuse hemorrhage. The microscope revealed a few areas that were suspicious of sarcoma, 
but no positive diagnosis could be made. I therefore dilated the cervix, palpated the interior 
of the uterus, and discovered a polypoid neoplasm wliich I regarded as a sarcoma. After 
extirpation of the uterus, the growth was found to be a simple mucous polyp. 

3 



34 GYNECOLOGICAL DIAGNOSIS 

The indications for dilatation and internal palpation of the uterus 
are therefore as follows: 

1. Great discrepancy between the clinical symptoms and the 
microscopic findings. If, for example, in an old woman, the presence 
of a malignant neoplasm is suspected on account of persistent hemor- 
rhage, and repeated microscopic examinations of scrap- 
ings fail to reveal anything but benign disease, so that no 

positive conclusion can be arrived at, the interior of the uterus should 
be explored. Internal palpation of the uterus, in such cases as this, is 
accordingly employed for the purpose of controlling or supple- 
menting the microscopic diagnosis. 

2. When in a case of repeated uterine hemorrhage, after the altera- 
tions have been positively shown to be benign by microscopic examina- 
tion, there is strong reason to suspect a cause for the hemorrhage, such 
as a polyp or a submucous myoma. In cases of this kind internal pal- 
pation is employed for the purpose of supplementing examination with 
the sound, which in the case of circumscribed polyps usually yields very 
uncertain results. 

A prerequisite for internal palpation of the uterus is that the cervix 
be sufficiently dilated to admit one finger. Spontaneous dilatation 
Dilatation of takcs placc wlieu polyps, polypoid myomata, sarcomata, 
the External Os. ^^ carcinomata are expelled. Quite frequently, however, 
the external os, in nulliparous women especially, offers prolonged 
resistance and has to be dilated in order to permit palpation. 

Dilatation of the external os is effected by dividing the vagi- 
nal portion on both sides. Under anesthesia, and after careful disinfec- 
tion of the external genitalia and the vagina, the vaginal portion is brought 
into view with a Simon or Sims speculum, the anterior and posterior 
lips are grasped with a Muzeux forceps, and the vaginal portion divided 
on both sides as far as the vaginal vault. A sufficient view of the dilated 
cervical canal is thus provided, the finger may be introduced for the 
purpose of palpation, and in many cases extirpation of the polyp may 
be done at once. The two incisions are then closed with interrupted 
catgut sutures, and the vagina is lightly packed with iodoformized 
gauze. The technique of the procedure is not difficult; it rarely fails, 
and may be recommended even to practitioners without special skill. • 
In most cases the entire cervical canal offers an obstacle 

Dilatation of _ 

the Cervical to internal palpation of the uterus. Incision of the entire 
cervix, either with bilateral incisions or by a median 
incision after pushing up the bladder, which has been recommended 
for the purpose of dilatation, is too severe a procedure for diag- 
nostic purposes. For routine practice the following methods are 
recommended: 



METHODS OF EXAMINATION 



35 





Fig. 19. — Hegar's Hard-rubber 
Dilators. ^. (Original.) 



1. Instrumental Dilatation. Hegar's dilators, which are made of 
metal, hard rubber, and glass, are the best instruments for the pur- 
pose. Metal dilators are the best, because most durable; a 

series ranging in thickness from the size of a sound to 
that of the finger is required (Fig. 19). After painstaking disinfection 
of the vulva, vagina and lower portion of the cervix, the vaginal portion 
is brought into view with a Simon or Sims 
speculum, drawn down with a hook, and suc- 
cessive numbers, beginning with the proper 
thickness, are then introduced one after the 
other. Even if the introduction is performed 
very slowly, and each number is left in place 
for several minutes, the dilating force of the 
instrument is so great that the cervical tissue 
may be ruptured. In dilating 
a closed cervix sufficiently to 
admit the finger, a more or 
less extensive laceration is 
almost certain to occur even 
when the tissues are soft and 

yielding. Hence this method of dilatation should be 
employed for purely diagnostic purposes only when the 
cervix is already in process of spontaneous dilatation, 
or for completing a dilatation begun with laminarla 
tents, when that method has proved inadequate. 

Dilatation of the cervix, such as is required for 
the purpose of exploratory curettage, is effected by 
the introduction of thin metal dilators like those 
designed by Schroder (Fig. 20) and Landau (Fig. 21). 
The dilatation is begun with a number approximately 
corresponding to a thick uterine sound, and gradually 
increased by the introduction of dilators of increas- 
ing thickness up to that of a moderately broad uter- 
ine curette. This method of dilatation should also 
be performed with a Simon or Sims speculum. 

2. Of all the contrivances at our disposal laminaria tents 
are the most reliable, and at the same time the least inju- 
rious. They satisfy better than any others the requirements of safe 
dilatation; that is to say, slow but sure, provided the antisepsis is 
adequate. 

Laminaria tents act by absorbing the secretions of the uterus 
until they swell up and forcibly distend the cervix; at the same time 
they tend to increase the blood supply of the cervical tissue, so that it 



Figs. 20 and 21. — 
Metal Dilators. Af- 
ter Schroder and Lan- 
dau. (Original.) 



Lamina- 
ria Tents. 



36 GYNECOLOGICAL DIAGNOSIS 

becomes soft and more susceptible of distention; besides, they induce 
labor pains, the effect of which is also to dilate the cervix. Laminaria 
tents (stems of s.ea-tangle, Laininar.ia . digitata) must be perforated in 
their long axis and armed with a thread, which is carried through the 
cervical canal and permits the removal of the tent (Fig. 22). It is not 
advisable to pass the thread through a hole in the lower end of the tent, 
because it is apt to tear out and leave the tent behind in the uterine cavity. 

Case 3. I once had a case in wliich the thread tore out and the tent disappeared 
behind the external os, and I had great difficiilty in extracting it. 

The following methods are recommended for 
the disinfection of laminaria tents: 

L The tents are placed, for some time before they 
are to be used, in a solution of iodoform in ether with 
an excess of iodoform. When the tents are removed, 
the ether evaporates and they remain covered with 
a thin layer of iodoform. 

2. The tents may be immersed one by one for 
twenty seconds in boiling water, and kept in a one- 
per-cent. alcoholic solution of bichlorid of mercury. 

Before introducing the laminaria tents, 
the external genitalia and the vagina must be carefully 
disinfected. The surest way to prevent the entrance 
ten't " Irm^d'^Z^ZT^I of organisms is to introduce the tents with the aid of 
foH^inaiT'*"^^'*'^' ^' ^ Simon or Sims speculum, thus avoiding contact 
with the vaginal walls. The vaginal portion is grasped 
with a hook and the cervical canal wiped out two or three times 
with a Playfair probe dipped in bichlorid solution. After again 
determining the direction of the uterus with the sound, the cervix 
is dilated with metal dilators up to 6 or 7 millimeters. The advan- 
tage of this preliminary procedure is that a laminaria tent of 6 or 
7 mm. in diameter can then be introduced, and this may be depended 
upon with certainty to dilate the cervix sufficiently for the intro- 
duction of one finger. The laminaria tent is then carefully introduced 
with a dressing forceps until it almost touches the fundus. If the 
vaginal portion is drawn well down, it is usually unnecessary to bend 
the tent so as to conform to the curve of the uterine cavity. A little 
iodoform gauze is then packed in front of the tent in order to prevent 
its slipping out again. The woman must be kept in bed, and the tem- 
perature taken every three hours; when 38.5° C. has been reached, 
the tent must be removed and the uterus disinfected. Twenty-four 
hours later the vulva and vagina are once more disinfected and the 
tent is removed by pulling on the thread. If the tent fails to come 




METHODS OF EXAMINATION 



37 



away, or threatens to break up, it must be seized with a strong cervical 
forceps and removed with slow rotating movements. The pain induced 
by this procedure, which is due to the downward pull on the uterus, 
can be mitigated by pushing both vaginal walls upward with the 
edges of the speculum. After the uterus has been carefully irrigated 
with a disinfecting solution, the examiner satisfies himself that the 
cervix admits one finger. If it does not, he proceeds to dilate with the 
corresponding numbers of Hegar dilators (usually up to 20). He is 
then ready to begin palpation, which usually has to be performed under 




Fig. 23. — Position of the Hands in Exploration of the Uterine Cavity. %. (Original.) 

anesthesia. Two fingers are introduced into the vagina, the index finger 
is strongly flexed and the middle finger, being the longest, is allowed 
to enter the uterine cavity through the dilated cervix. 

[In the digital examination of the uterine cavity, either a 
sterilized rubber finger-cot or rubber gloves should invariably be 
worn. — Editor.] 

At the same time the examiner grasps the uterus with the other 
hand, effects a slight retroversion, and invaginates the abdominal wall, 
pressing the fundus down on the palpating finger (Fig. 23). This is 
necessary in order to make sure that the internal finger reaches the 



38 GYNECOLOGICAL DIAGNOSIS 

fundus. The examiner should push the finger up against the fundus 
and, by rotating it from side to side, try to obtain some idea of the 
character of the uterine cavity. After palpation has been completed, 
the uterus is once more irrigated and the patient kept in bed two or 
three days. It is not wise to attempt dilatation in the office or dispensary. 
Sometimes the pain is severe enough to require full doses of opium. 
The temperature must be carefully watched in order to recognize the 
first indication of infection as soon as possible. 

As dilatation by means of laminaria tents increases the blood 
supply of the uterus, induces labor pains, and causes traction on the 
surrounding tissues, the procedure is very apt to cause exacerbations 
Contra- of perimetritic or parametritic inflammations. For this 

indications. rcasou it should not be employed in cases of recent inflam- 

matory disease in the adnexa, in tubal disease, or in the presence of 
hematoma in the peritoneum and broad ligament; and the structures 
around the uterus must, therefore, always be carefully examined before 
dilatation is done. The presence of virulent catarrh also makes it im- 
possible to introduce a laminaria tent. When the uterine cavity con- 
tains decomposed material, the procedure should also be avoided, if 
possible; it may have to be employed, however, because the diagnosis 
and removal of such material is very frequently impossible without 
previous dilatation of the cervical canal. In cases of this kind careful 
disinfection is particularly important. If the above-mentioned contra- 
indications are kept in view, and dilatation is performed only when the 
structures surrounding the uterus are in a healthy condition, the pro- 
cedure is free from all danger. It must always be remembered that 
the most painstaking antisepsis is necessary. The repeated introduction 
of laminaria tents for gradual dilatation is to be avoided because it 
greatly increases the danger of infection. 

Microscopic Diagnosis. 

We are not unfrequently limited in our diagnosis of disease of 
the mucous membranes in the female genitalia by the fact that 
the diseased tissue, especially of the body of the uterus and upper 
portion of the cervix, is not accessible either to the eye or the palpating 
finger; while in other cases our diagnostic efforts are frustrated by the 
fact that the changes in the mucous membrane, in the vaginal portion 
for example, are not sufficiently characteristic to be attributed with 
any degree of certainty to a definite disease. In such cases a positive 
diagnosis may be reached by means of the microscope, since the histo- 
logic picture reveals specific tissue changes. The microscopic examina- 
tion is therefore an auxiliary method, to be employed when all other 
diagnostic means have failed; and its scope is accordingly somewhat 



METHODS OF EXAMINATION 39 

ill defined. In disease of the mucous membrane of the body, in which 
inspection is of no use whatever and palpation often fails to supply any 
information, curettage of the uterus with microscopic examination of 
the scrapings is a most important resource even to the most experienced 
specialist. It is remarkable what surprises the microscope often prepares 
even for the most experienced diagnostician. Carcinoma is often dis- 
covered with the microscope in cases in which it had not been suspected, 
and, conversely, when the clinical symptoms point to carcinoma, the 
microscope may fail to confirm the diagnosis. For this reason it is 
urgently recommended that the scrapings obtained from the 
uterus be subjected to microscopic examination in every 
case. Whenever curettage is performed for therapeutic purposes it 
should also, in a sense, be an exploratory curettage. In diseases of the 
vaginal portion, however, the experienced eye and the practised finger 
are excellent diagnosticians, and the expert specialist will therefore 
rarely be obliged to excise a piece of tissue for the purpose of microscopic 
diagnosis. Not so the general practitioner, however. Owing to his 
limited experience he will often feel changes in consistency in the vaginal 
portion which will arouse the suspicion of malignant infiltration; or 
he may see changes in the mucous membrane the nature of which he 
is unable to entirely understand. To clear up every doubt of this kind 
with the microscope is hardly practicable because the necessary anatom- 
ical material cannot be obtained without great inconvenience and loss 
of time to the patient, even though the procedure may be without danger.* 
The early diagnosis of uterine cancer has placed exploratory curet- 
tage and the excision of a piece of tissue in the front rank of diagnostic 
methods, and demands their application by every practising physician. 
The life of a cancer patient not infrequently depends on the conscientious 
employment and correct technique of these two methods for obtaining 
anatomical material, and they will therefore be described at length. 

Exploratory Curettage. 

The purpose of exploratory curettage is to obtain particles of tissue 
from diseased spots on the mucous membrane which cannot be seen; 
or, in other words, from the entire body of the uterus and the upper 
portion of the cervix. As in most cases there is no means of knowing 
at which point in the uterus the alteration which is to be subjected 
to microscopic examination has developed, it is not enough to obtain 
pieces of tissue only from definite portions of the organ, as when a 



* That this comparatively trifling procedure may occasionally be fraught with danger 
is shown by an experience of Steinbuchel, who had a death from sepsis following curettage, 
probably due to an infected Nabothian follicle; hence the procedure should be resorted 
to only for the piu^pose of diagnosing changes which raise a suspicion of malignant disease. 



40 GYNECOLOGICAL DIAGNOSIS 

piece of tissue is excised from spots in the vaginal portion which 
the eye has previously recognized as being suspicious. If in palpa- 
ting the interior of the uterus definite changes have been felt in the 
organ, the nature of which cannot be determined by palpa- 
curette^r^ tion, it may be justifiable to secure the tissue from 
the suspected portions; but it is not proper to go by 
what is felt with a sound, since circumscribed areas of roughness are 
very frequently found in that way. The surest way to avoid missing 
a circumscribed neoplasm is to scrape the entire intra-uterine surface 
and the upper cervical portion in a systematic manner. In the case 
of circumscribed changes the scrapings always contain a mixture of 
sound and diseased tissue; hence another danger of overlooking the 
disease if only certain portions, which macroscopically perhaps look 
suspicious, are placed under the microscope. The only sure method 
of guarding against an oversight is to examine ail tissue obtained by 
the curette under the microscope; hence, in order to obtain all the 
pieces, the cervix must be sufficiently dilated to enable them to escape 
from the uterus, when they must be carefully collected. 

The technique of exploratory curettage is as follows: 
The patient must be anesthetized so that the curettage may be 
complete. An anesthetic may be dispensed with, however, when it 
is desired merely to obtain a portion of a tumor which can readily be 
reached when the cervix is open. A physician for administering the 
anesthetic and possibly an assistant for holding the instruments are neces- 
sary. The following are needed: Simon's or Sims' speculum, uterine 
sound, double tenaculum, irrigators, uterine catheter, two curettes 
(broad and narrow), and metal dilators. The patient is placed on an 
examining-chair, and the vulva, vagina, and vaginal portion are care- 
fully disinfected. A Simon or Sims speculum is then introduced, the 
vaginal portion brought into view, and the anterior lip grasped with a 
tenaculum. After ascertaining the direction of the uterine cavity with 
a sound, the cervix is dilated until it admits a moderately broad curette 
and the uterus is irrigated. Curettage then begins. and, in order to 
make quite sure of reaching every portion of the uterine wall, a certain 
method should be followed: First, the anterior wall is scraped down 
with parallel strokes; then the posterior wall; then the fundus; then 
the right lateral angles; then the left; and finally the upper portion 
of the cervix. The curette must be manipulated with great care, espe- 
cially when it is carried up into the uterus, as a carcinomatous or senile 
wall is very easily perforated, and the accident may be followed by peri- 
tonitis if the neoplasm has broken down. The scrapings begin to appear 
at the cervix during curettage, and what is left is later obtained by 
irrigation, which completes the procedure. All the pieces of tissue 



METHODS OF EXAMINATION 41 

must be carefully collected and at once placed in a hardening fluid. The 
patient should remain in bed from four to five days. 

The cases for exploratory curettage are in the main those in which 
clinical symptoms raise the suspicion of malignant disease of the uterine 
mucous membrane, i.e., carcinoma, sarcoma, and chorionic epithelioma. 
A microscopic diagnosis may also be desired when there is a suspicion 
of tuberculosis of the uterus, because the question of operation or of 
specific treatment depends on its results. Doubtful cases of extra-uterine 
pregnancy could be cleared up by demonstrating the presence of decidua 
in the uterus through a microscopic examination, but the procedure is 
not permissible under these circumstances because it might lead to 
rupture of the gestation sac and suppuration of the hematocele. For 
the diagnosis of simple changes in the mucous membrane such as 
endometritis, or the remains of an abortion, exploratory curettage is 




Fig. 24. — Goodell-Ellinger Dilator. 

not in itself allowable; but after it has been performed for therapeutic 
reasons, the clinical diagnosis should in every case be confirmed by a 
microscopic examination of the scrapings. 

[The dilator usually employed in America is the Goodell-Ellinger, 
which effects the dilatation either by a rapid rotary movement or 
slow divulsion by means of a set screw. — Editor.] 

Exploratory Excision. 

Excision of a piece of tissue is a method that is available only when 
the diseased parts are easily accessible to the knife or scissors, such as 
the vaginal portion and the lower portion of the cervix (also, of course, 
the vagina and vulva). This method has an advantage Exploratory 
over exploratory curettage in that it permits the removal of Excision. 

definite portions of tissue which appear suspicious to the finger or to the 
eye. The junction between healthy and diseased tissue should be 
selected for the excision, in order to have the advantage of comparison 
in making the diagnosis. 



42 GYNECOLOGICAL DIAGNOSIS 

This procedure can always be performed without anesthesia because 
it is painless, and no assistant other than a nurse is required. The 
necessary instruments are the Simon or Sims speculum, irrigator, 
long-handled knife, large forceps, double tenaculum, catgut, needle- 
holder, needle, and iodoformized gauze. 

The technique is as follows: The patient is placed on the 
examining-chair and the vulva, vagina, and cervix are carefully disin- 
fected. The cervix is then brought into view with a speculum and 
drawn down as near as possible to the introitus by grasping the anterior 
lip with a tenaculum. At the edge of the suspicious spot a wedge of 
tissue about 1 to 1.5 cm. long, 0.5 cm. broad, and about 0.5 cm. thick, 
is then excised. The hemorrhage, which is usually slight, can be arrested 
with one or two catgut sutures. The vagina is packed with iodo- 
formized gauze for a day or two, and the woman kept in bed for two or 
three days. The excised tissue is at once placed in a hardening fluid. 

The procedure is indicated chiefly in the presence of changes 
in the mucous membrane that suggest carcinoma or sarcoma. In 
addition, however, other morbid processes, such as tuberculosis and 
syphilis, occur in the cervix, the clinical appearance of which is not 
always sufficiently characteristic to make a diagnosis by inspection 
or palpation possible, and in such cases it is often desirable to obtain 
indications for treatment by means of a histologic diagnosis. Benign, 
non-specific processes do not require microscopic examination, and in 
the employment of this procedure as well as in exploratory curettage 
there should be a limit to diagnostic zeal. 

Microscopic Examination. 

The purpose of microscopic examination is to recognize conditions 

which are too minute to be ascertained by the unaided eye. In the 

microscopic examination of fluids the cellular constituents and bacteria 

present are studied. Fluids that are poor in cellular ele- 

Purpose. . . n'l in-ii"ii 

ments, such as urme, ovarian fluid, and fluid obtained by 
puncture, must be filtered and the filtrate examined; or allowed to 
settle in a conical glass and the sediment picked up with a pipette; or 
centrifugated and the sediment taken up drop by drop with the pipette 
Examination ^ud Submitted to examination. Thick, mucoid fluids that 
of Fluids. ^j,p j.-p|^ jj^ cellular constituents, such as vaginal secretion, 

spermatic fluid, blood, pus, cervical or uterine secretion, are at once 
diluted with a drop of water, or a little physiologic salt solution (0.6 to 
0.7 per cent.), glycerin, or a solution of iodin and potassium iodic! (one 
part Lugol and three to four parts water), spread out on the slide with 
the needle, and placed under the microscope. Shreds of tissue found in 
the fluid are treated in the same manner as scrapings, either fresh or 



METHODS OF EXAMINATION 43 

hardened (see below). — Bacteria are studied by special methods: A 
minute portion is rubbed on a cover-glass or thinly distributed by 
lightly pressing it between two cover-slips, drawing them Bacterial 

apart and allowing them to dry in the air; or the back of the Examination. 
cover-slip is cautiously passed through the flame. The dry preparation, 
thus obtained, is then covered with a few drops of the stain (methy- 
lene blue, gentian violet, or fuchsin), slightly warmed in most cases, 
rinsed in water, and again dried as above. It is then either mounted 
at once in Canada balsam, or, if certain bacteria are to be distinguished 
from others, these are stained with the specific staining mixture for 
the purpose of counter-staining, and then the remaining bacteria are 
stained with some other stain as described above (double-staining — 
counter-staining). — The special methods of demonstrating, 1, gonococci 
(diagnosis of gonorrhea); 2, tubercle bacilli (diagnosis of tuberculosis); 
3, pyogenic micro-organisms (staphylococci and streptococci), will be 
described at length in the chapter on bacteriologic diagnosis (page 64). 
— The bacterium coli appears as short rods, often of irregular out- 
line. — In the vaginal secretion or in the vagina the mycelium of oidium 
albicans (thrush) and the parasite trichomonas vaginalis are 
often present. — 

Microscopic examination of tissues is made for the pur- 
pose of recognizing the minute composition, and particularly for the 
purpose of determining whether there are any pathologic deviations, and 
if so, what may be their nature. We desire to distinguish Examination 
between simple and inflammatory affections and other of Tissues, 

specific alterations to determine whether the degeneration present is 
benign or malignant in character. — The tissue to be studied, whether 
it be scrapings or the excised portion of a tumor, may be examined 
without any special preparation (examination of (a) of Fresh 
fresh material). The final diagnosis can often be made Material, 

at once. — Minute pieces of tissue are picked out with a small forceps 
(or with scissors or knife) from the selected material, placed on a 
slide in water, glycerin or a solution of iodin and potassium iodid 
(see above), and teased out with a needle. In this way chorionic villi 
can be identified at once by their epithelial covering and epithelial 
processes, and differentiated from vessels, which often resemble them, 
thus establishing the diagnosis of abortion or the post-partum state. — 
Sarcomatous changes in a myoma can thus be diagnosticated; uterine 
glands are readily isolated and identified by their characteristic, often 
ciliated, epithelium. — Instead of .teasing out minute particles of the 
suspected material, the tissue juice may be scraped off with a knife, 
especially when the pieces to be examined are large. The cellular 



44 GYNECOLOGICAL DIAGNOSIS 

elements suspended in the tissue juice often supply the data for the 
most important diagnostications, or at least point the way to further 
investigation. — Finally, sections may be made of the material to 
be examined if the pieces have the necessary size and consistency; if 
the material is soft, the double knife with parallel blades should be 
employed. In the sections the individual portions of the tissue retain 
their normal connections. In addition to Lugol's solution, Loffler's 
methylene blue or an acid fuchsin solution may be employed. — The 
examination of recent material, like every other method, requires 
practice, and should never be neglected. 

Very often, however, the tissue to be examined — particles of 
tumor and the like — require special preparation for micro- 
scopic examination. It is not enough to tease out portions of ma- 
(b) Of Hani- terial or to examine recent secretions; the supply is too 
ened Material. limited, and it bccomes important not to waste any part of it. 
In such cases the material to be examined must be hardened. 
The shreds of tissue, scrapings, or the pieces obtained by excision, 
should be placed atonce in a 96 per cent, alcohol, or absolute alcohol, 
without previous washing. As a preliminary procedure it is well 
to shake up the shreds of tissue with a little alcohol until the blood 
which adheres to the tissue (in small clots and in mucus) has been 
coagulated, after which the pieces are poured out into another dish, 
from which they can readily be isolated and placed in fresh alcohol for 
the final hardening (preliminary selection before final hard- 
ening) . — If the material is treated in this way, the surface of the pieces 
of scrapings, their character, which is often spongy in fungous endo- 
metritis, as well as the line of section of an excised piece, can easily be 
recognized — an important point for the direction of the microtome 
knife at subsequent sectioning. If the tumor or other diseased tissue 
to be investigated is extensive, the excised piece should not be too large. 
It is better to take several pieces from different parts of the tumor — 
0.5 cm. square and 0.25 cm. thick. — In a short time, one-half hour to 
one or two hours, the material is ready for sectioning, and may then 
be cut into very thin sections in any desired plane with the razor. — 
Besides alcohol, Miiller's fluid or formalin (either dilute or concen- 
trated) may be employed for hardening. For purposes of diagnosis 
these solutions are perfectly satisfactory. There are, besides, Zenker's 
solution, bichlorid of mercury solution and Flemming's solution. In 
examining scrapings or shreds of tissue which are mixed with blood, it 
is always best to shake them up in alcohol as described, and place them 
in fresh alcohol for hardening without previous rinsing; in all other 
respects the method is the same as just described. — An important 
preliminary treatment of the material to be examined consists in freez- 



METHODS OF EXAMINATION 45 

ing, and sectioning with the freezing-microtome. For freezing ether 
or compressed carbon dioxid may be used. The sections are "planed," 
placed in water, and then, if desired, fixed in formalin or 
alcohol, after which they are ready for examination; but pfoz^en'sections! 
even when the freezing-microtome is deployed it is always 
best to subject the scrapings or excised piece of tissue to a pre- 
liminary hardening in absolute alcohol (see above), remove the alcohol 
with formalin, and the latter with water; or to harden directly in formalin 
and then wash in water. As the pieces of tissue in such cases are usually 
small, this procedure requires no more time than freezing fresh material. 
The whole process can be completed in from one to two hours, or even 
less if the pieces are small. — Difficulties which occasionally arise when 
the sections are made at once with the freezing-microtome without 
previous preparation of the material, such as blurring of the microscopic 
picture, are in this way avoided. A rapid diagnosis based on sections 
obtained with a freezing-microtome, without previous hardening, may 
be unreliable in an individual case, and is usually not necessary. 

It may happen that hardening with alcohol, Miiller's fluid, formalin, 
Zenker's solution, bichlorid or Flemming's solution, without embed- 
ding, may not be sufficient even for diagnostic purposes. The indi- 
vidual portions are not sufficiently held together, and go Method of 
to pieces in the washing, staining and mounting. For Embedding, 
this reason embedding is a third method of extreme impor- 
tance for diagnostic purposes. It is employed more than any of 
the others because with a little care it combines the advantages of the 
other methods, and has special advantages of its own, particularly the 
ease with which serial sections can be prepared. — - 

For the microscopic examination of gynecological specimens, 
particularly for diagnostic purposes, embedding in celloidin is 
the best method. — The celloidin is dissolved in ether, and solutions 
of varying strength are prepared ("thick celloidin" — "thin ceiioidin 

celloidin"). The longer the preparation can be soaked in Method. 

the celloidin the better will be the sections. The material to be studied, 
the size and preliminary preparation of which have been discussed, is 
first completely dehydrated in absolute alcohol; it is then placed in a 
mixture of ether and alcohol for from one to two to twenty-four hours, 
depending on the size of the pieces; then in thin celloidin solution, whjch 
is gradually replaced with stronger solutions. The imbibition 
should be as nearly uniform as possible, — from two to four to 
twenty-four hours, depending on the size of the pieces, may suffice. — 
The pieces are then "cast"; that is, they are placed in a small, round 
glass vessel or adjustable metal receptacles, which can be adapted to 
the size of the object, or into little boxes or baskets made of paper. 



46 GYNECOLOGICAL DIAGNOSIS 

— The pieces are then so placed that the sections will be 
made in the desired plane. — The celloidin cast is now placed 
under a glass bell-jar until it has evaporated to a soft elastic con- 
sistency; the masses of celloidin, with or without the containing 
vessel, are then placed in 66 per cent, alcohol, in which the celloidin 
around and in the pieces of tissue becomes fully hardened. — These 
hardened masses are glued to blocks of wood with celloidin, after 
clipping the blocks for a few moments in ether and alcohol, or alcohol 
alone, to make the celloidin adhere. The blocks may be of earthen-ware 
instead of wood. Pieces of cork were formerly employed, but have 
been discarded because they exude substances which interfere with 
the tingibility of the embedded masses. — ■ 

This ends the process of embedding, and the pieces remain 
in 66-per-cent. alcohol, either whole or in sections, and may be exam- 
ined under the microscope at once, or kept for later study. — The sections 
should be made with a microtome, although they can be made by hand. 
— The sections are removed from the microtome with a brush or the 
tip of the finger, and placed in water; they are then stained, washed, 
dried as well as possible with filter paper, and placed in 96-per-cent. or 
in absolute alcohol, in order to remove the last remains of water from 
the preparation; but the sections must be removed from the alcohol 
as soon as the celloidin begins to soften and dissolve. They are then 
placed in carbol-xylol, laid on the slide, the carbol-xylol removed, 
and the preparation mounted in Canada balsam. The sections must 
be transparent. If they contain whitish spots that do not clear up, 
it is a sign that dehydration has not been complete, and the procedure 
must be repeated. 

The only other embedding material besides celloidin that deserves 
mention is paraffin. Embedding in albumin or in a mixture of 
gum arable and glycerin, while it has its advantages, may be passed over. 

Embedding in paraffin is suitable for small, soft pieces of 

tissue. The pieces to be embedded require the preliminary treatment 

with alcohol as when celloidin is used. After dehydration in alcohol 

the tissue is placed in xylol, and paraffin gradually added 

Paraffia Method. i i • • i • i t i • i 

until a saturated solution is obtained. In this way the 
tissue becomes thoroughly saturated with xylol, xylol-paraffin. — The 
xylol is gradually evaporated in a thermostat by raising the tempera- 
ture to 50° C; and finally the tissue to be examined is embedded in 
the congealing paraffin by cautious but rapid cooling. — The tissue is 
then trimmed up, glued to the block of wood (cork or metal base) 
with paraffin, and cut with a paraffin-microtome, which is placed 
vertically to the object, in contradistinction to the position of the 
knife in cutting celloidin preparations, when the edge of the knife is 



METHODS OF EXAMINATION 47 

drawn lengthwise over the cut surface, keeping the edge of the blade 
in contact with the tissue as long as possible. — The sections are readily 
floated out in water and placed on the slide, which is first painted 
with albumin-glycerin, so that the sections will adhere. The section 
is then dried in the thermostat by raising the temperature to 37° C, 
covered with xylol, and mounted in Canada balsam. — As a rule the 
sections are previously stained in toto (staining of the entire piece); 
if not, they are now placed in water, then in the stain and, after 
washing, in alcohol, xylol, and Canada balsam. With a suitably 
prepared right-angled block, tissue embedded in paraffin can readily 
be cut in serial sections. The sections, which form a continuous 
"ribbon," are placed in water and then on the slide, and numbered 
before they are mounted. — 

Sections prepared for microscopic examination are stained so 
as to differentiate the details of the histologic structure. The meth- 
ods of staining recent material have been discussed. For 
hardened or embedded sections there are various stains and staining of 

a variety of methods and combinations (double staining). the Sections. 
Not only the nuclei, but the protoplasm of the elements as well, and 
the outlines of the cells should be stained with the greatest possible 
uniformity and expedition. — The simplest method, and one which in 
most cases is perfectly satisfactory, consists in staining the sections 
with alum-carmine, as there is no danger of over-staining. When 
celloidin sections are left in the stain too long, the celloidin often becomes 
colored and confuses the microscopic picture. In many cases a few 
minutes suffice for this purpose. After the excess has been washed off, 
the section is placed in alcohol for the purpose of dehydration and, before 
the celloidin has begun to dissolve, in alcohol and xylol-carbol. It is then 
placed on the slide, the xylol-carbol removed, and the section mounted 
in Canada balsam. — A still more complete differentiation is obtained by 
means of haemalaun, but the section must not be allowed to remain 
more than a short time, often only from one-half to one and a half 
minutes, in the fluid. Haemalaun will stain necrotic tissue that is not 
affected by alum-carmine. — The haematoxylin method is also to 
be recommended. Counter-staining (double staining) is effected by 
means of eosin, picric acid or van Gieson's fluid. The 
sections are placed a few minutes (from eight to ten or twelve) in the 
haematoxylin solution, then in an acid solution (containing hydrochloric 
acid) from one to two or three minutes for the purpose of differentiating, 
washed in water, dehydrated in absolute alcohol for from one-half 
to two minutes, cleared in carbol-xylol and mounted in Canada balsam. 
— For the purpose of counter-staining (double staining), the sections after 
passing through haematoxylin are placed in an alcoholic solu- 



48 GYNECOLOGICAL DIAGNOSIS 

tion of eosin from one to two minutes, and then thoroughly dehy- 
drated in alcohol, which to be sure removes part of the eosin. — In van 
Gieson's method the sections are somewhat over-stained with 
hscmatoxylin and then placed for from three to five minutes in a solu- 
tion of .picric acid and acid fuchsin, quickly washed in water (one- 
half minute), dehydrated in alcohol, cleared in xylol, and mounted in 
Canada balsam — the muscle fibres are stained yellow, the connective 
tissue red. — 

There are quite a number of other excellent methods, and each 
of them undoubtedly has its special value for one who is 
familiar with the particular method: lithion-carmine, 
borax-carmine for soft embryonal tissue. Excellent pictures can be 
obtained by treating the sections with liquor ferri sulphatis oxidati (one 
part to two of distilled water), either by itself or with a counter-stain; 
the sections are first soaked in distilled water and placed from two to 
twenty-four hours in the above solution; then for from one to twenty- 
four hours in yellow ha'matoxylin (the latter must be dissolved in 
absolute alcohol and then mixed with distilled water) until the solu- 
tion has approximately the same color as the caustic staining solution; 
later this solution turns dark, almost black, which however does not 
interfere with its usefulness. When the sections are first taken from the 
solution they are almost black and are placed in hydrochloric acid 
solution (10 : 100) or in glacial acetic acid (30 : 100) (slow method) 
for the purpose of differentiation, until the color becomes sufficiently 
brown; they are then rinsed in distilled water and immersed for some 
time in running water until the color is a beautiful, intense blue 
(Benda's method). 

A very beautiful method, which is quite as good as the somewhat 
complicated one of Benda and requires less time, is that of Weigert. 
The following solutions are employed: (a) One gram of hsematoxylin 
in 100 c.c. of 96-per-cent. alcohol; (b) 4 c.c. of sesquichlorid of iron 
solution, 1 c.c. of official hydrochloric acid, and 95 c.c. of water. The 
solutions a and b are freshly mixed in equal parts each time; the 
black mixture which results is ready for use in a few minutes. — The 
sections are then rinsed in water and briefly immersed in a mixture of 
saturated solution of picric acid, 100 parts (at room temperature), 
and one-per-cent. watery solution of acid fuchsin, 10 parts, hastily 
rinsed in water, dehydrated in 96-per-cent. alcohol, cleared in carbol- 
xylol, and mounted in Canada balsam. 

The following points are of importance in preparing sections for micro- 
scopic examination: (1) The plane of section. Since changes 
in the mucous membrane are most frequently the object of 
gynecologic diagnosis, whether the tissue to be examined is obtained 



METHODS OF EXAMINATION 49 

by curettage or by excision, the plane of section should be as nearly 
as possible perpendicular to the surface of the mucous membrane, 
in order to obtain sections of the deeper portions of the tissue. If 
the recent scrapings are treated with alcohol as described 

, , . . . Preparation of 

above, the material again examined, and the pieces of tissue Microscopic 

. Sections. 

suitably placed in celloidm, the plane of section can be 
perfectly controlled. Although the scrapings often contain such an abun- 
dance of particles which, when embedded in toto, present longitudinal, 
as well as transverse and oblique sections even without preliminary 
selection, nevertheless the certainty with which the plane of section can 
be influenced by selecting the pieces beforehand is worth the trouble, 
which is not very great. — When a piece has been obtained from the 
centre of a tumor, the plane of section should, if possible, be made 
double, i.e., in two planes superimposed vertically one above the other; 
quite often the double direction is unnecessary, however, as the 
picture obtained with the first may give all the necessary infor- 
mation. (2) The thickness of the sections must be uniform. This 
demands good embedding and a sharp knife. (3) The sections must 
be in the same plane and not wavy. The use of an Thickness of 
excessive amount of Canada balsam in mounting is to be the sections, 
avoided. Later a small weight (piece of lead) may be laid on the 
cover-glass to assist in spreading the preparation out uniformly. (4) 
The staining must be properly carried out (see above). (5) The 
sections selected for diagnostic purposes must be neither too thin nor 
too thick. For a general study with low magnification 
sections from 15 to 20 p. are sufficient, and for finer study, 
from 10 to 15 p.. Some specimens must be cut thin, while for others 
thicker sections are equally satisfactory. In the case of villi, decidual 
tissue and sarcoma thin sections are to be preferred; simple hyper- 
plastic changes of the endometrium can be studied better when the 
sections are somewhat thick. — (6) The sections should be placed on 
the slide in such a way that the surface of the mucous membrane 
is parallel to one side of the slide; in the case of inflammatory changes 
in which, for example, the glands of the uterus usually 

' '^ Position of 

proliferate far beyond their normal limits in the muscle. Section on 

it is a great convenience to have well-placed microscopic 
preparations. — (7) A most important step in the examination consists in 
careful inspection of the sections with the unaided eye 

.... "^ Careful 

tor the purpose of orientation. With a very low magnifi- Macroscopic 
cation, from two to four diameters, as with an ordinary 
loupe, much of the composition of the tissue and many pathologic altera- 
tions can be seen. Even with the unaided eye the dilated uterine glands 
in fungous endometritis are quite visible; the cancerous alveoli are 

4 



50 GYNECOLOGICAL DIAGNOSIS 

quite distinct; in stained preparations the edge of the mucous mem- 
brane stands out sharply. With a httle practice mere inspection of the 
microscopic preparation will enable one to make a provisional diagnosis 
of abortion {status post abortum). After the section has been studied 
with a lo,w magnification (1 to 20, with a loupe) the sections are worked 
up with a higher magnification — from 50 to 100 times suffices to clear 
up everything in most cases. — It is extremely important to get a general 
idea of the preparation under low power and to make a provisional 
diagnosis. Indeed, in many cases low magnification suffices for the 
final diagnosis; while, on the other hand, there are changes which can 
only be positively diagnosed with high magnification, such as certain 
decidual changes and sarcomatous degeneration. 

Microscopic examination may be demanded for a variety of reasons. 
It may be desired to confirm the clinical diagnosis, even if it does not 
seem to be necessary. Sometimes a clinical diagnosis which is appar- 
ently positive has to be revised after a microscopic 

Purposes of _ _ ^ 

Microscopic examination has been made; for example, a uterine tumor 

Examiuation. . . 

said to be malignant has been recognized later as the remains 
of an abortion (greatly altered placental polyp). In the second place, 
it may be required to clear up doubtful cases in which no positive 
clinical diagnosis can be made. Contradictory views of individual 
examiners, as, for example, whether a degeneration of the vaginal portion 
is malignant or not, are settled by the microscope by examining an 
excised portion or the scrapings. — Alterations which are not recognized 
clinically, as to the benign nature of which, for example, there appears 
to be no doubt whatever, may be positively demonstrated to be 
malignant by the microscope. — Microscopic examination is resorted to 
Early ^^Y the purposc of recognizing the existing conditions as 

Diagnosis. early as possible, in order that treatment, if neces- 

sary, may be applied early and the corresponding prognosis made. 
The waiting policy — ex juvantibus ex nocentibus — has very scant 
application in gynecology. — 

There are numerous sources of error to be guarded against 
in microscopic examination. In the first place, the material supplied 
for examination maj' be unsuitable or insufficient in quantity. In a 
Sources suspicious casc of malignant degeneration of the uterus the 

of Error. focus may bc quite small, or situated in the angle of the 

tube so as to escape the curette, and in such a case the diagnosis based 
on the scrapings may be erroneously favorable, and the apparently 
exact microscopic proof of benign alterations may prove fatal to the 
patient. Although in cases of this kind the material supplied to the 



METHODS OF EXAMINATION 51 

pathologist, and not a faulty examination, is responsible for the faulty 
diagnosis, mistakes may occasionally be due to the fact that the pieces 
examined are too small, as when a diagnosis is based on a teased 
preparation, or on a spread of the tissue juice. A sarcoma cell is diffi- 
cult to distinguish from a decidual cell, for the latter must be regarded 
as the physiologic type of the former. A small-celled sarcoma cannot 
be distinguished from inflammatory infiltration if only small portions 
of the tumor are examined. The individual element of a malignant 
adenoma — the cylindrical cell — can hardly be distinguished from the 
cell of a glandular endometritis. Particles of squamous epithelium 
simulate cancer nests. — While examination of teased specimens and of 
recent material should not be neglected, and it is quite true that it 
may afford indications for still further investigation or even suffice for 
making the diagnosis, it is nevertheless preferable in the main to 
depend for a gynecologic diagnosis on regularly pre- 
pared, embedded and sectioned material. Even a minute 
piece of tissue, barely as large as a lentil, may, if properly worked up, 
give positive information and furnish the basis of a definite diagnosis. 
The most minute particles of tissue not infrequentlj^ suf- 
fice for the diagnosis of malignant neoplasms. — On the other 
hand, even when the tissue has been well prepared and well embedded, 
and the staining properly carried out, the interpretation may be exceed- 
ingly difficult. Thus, the diagnosis of a specimen from hydatid mole, 
when persistent hemorrhage clinically arouses a suspicion of malignant 
degeneration and the' scrapings contain large syncytial masses among 
the muscular and decidual elements, may present the greatest difficulties. 
— While occasionally minute pieces suffice for a diagnosis, in other 
degenerations the diagnosis may be difficult even when large portions 
are examined. — It is very difficult to determine whether abundant, 
so-called "syncytial migratory cells" are benign or malignant. — 
Another source of error arises from deceptive appearances in the prep- 
arations themselves, which will escape all but the practised eye. — Hori- 
zontal and longitudinal sections of glands and of the fundi of glands 
are apt to simulate multiple layers; changes consisting in Deceptive 

conversion into epithelial tissue (epidermidalization) are Pictures, 

apt to simulate beginning carcinoma, particularly when the line of 
section is not vertical; changes in and around polypi may look like 
malignant degeneration; and the glands of pregnancy are apt to suggest 
the diagnosis of glandular carcinoma. — 

Aside from these sources of error, which can be avoided by care and 
practice, or by examining the specimen from a second curettage or 
excision, there may be occasionally certain other insurmountable 
difficulties, as, for example, in the beginning of a malignant degeneration. 



52 GYNECOLOGICAL DIAGNOSIS 

— The limitations of microscopic diagnosis in this respect are 
such as to baffle even the most practised observer. In a tuber- 
culous ulcer it may be impossible to demonstrate either tubercle bacilli 
or giant-cells. — In spite of its limitations microscopic 

Limitations _ _ 

of Microscopic' examination plays a most important part in gyne- 

Diagnosis. . . , . ■ -ri. c i i 

cologic diagnosis, it ot course presupposes a knowl- 
edge (a) of the normal structures, and (b) of pathologic changes. 
Practice eliminates most sources of error and reduces the limitations to 
their minimum. One of the best exercises for developing the observer's 

skill and making him quick to note sources of error consists 

Prerequisites _ _ . . 

of Microscopic in making drawings of microscopic preparations: when 

Diagnosis. , . , 

one attempts to reproduce correctly on paper what we have 
seen, one is forced to observe accurately. 

A not unimportant factor in the success of microscopic examina- 
tion is the preparation of the material to be examined, and 
the way in which the piece has been removed or excised. The material 

is obtained by curettage and by excision, and the method 

Treatment of . . 

Material to of treating this material has been given. It is, however, 

exceedingly important, before cutting up a preparation, 
and in fact before touching it, to make a careful inspection. With 
a little practice one learns to pick out the part best adapted for 
microscopic examination. But as it is not always possible to see 
everything clearly and select the desired portion of the material, we 
should make it a rule not to destroy anything and not to 
frustrate a subsequent examination by unskilful sectioning and cutting 
out of pieces — a sure sign of ignorance — as, for example, cutting out 
unnecessarily large, four-cornered blocks. In most cases flat pieces or 
disks from two to three mm. wide are large enough. There is room for 
artistic excellence even in preparing the material. 

Cystoscopy. 

Cystoscopy has become an indispensable aid to gynecologic exam- 
ination. Diseases of the female genitalia and diseases of the bladder 
are in many respects very closely related. Some diseases, on the one 
hand, develop simultaneously in both the reproductive and the uri- 
nary apparatus, as gonorrhea, tuberculosis and fistula; while, on the 
other hand, diseases of the bladder are prone to develop in the course of 
some gynecologic affection. Thus, a carcinoma of the uterus may 
extend to the bladder, purulent cystitis may result from rupture of 
an exudate, a tumor, or a pyosalpinx. Functional disturbances of the 
bladder caused by diseases of the genital organs are even more frequent 
— ischuria with pelvic tumors, tenesmus from stenosis of the lumen, 
distention of the fundus of the bladder, myomata of the gravid uterus, 



METHODS OF EXAMINATION 



53 



sacculations of the bladder in prolapse. The spatial and functional 
association of the urinary apparatus with the genital organs in itself 
usually brings women who are suffering from disease of the bladder 
to the gynecologist, who, even if he confines his practice strictly to 
gynecology, is therefore forced to familiarize himself with the diag- 
nosis of vesical diseases. 

According to Knorr, 663 out of 3213 patients who came to his gynecologic dispensary, 
or 20.6 per cent., complained of vesical symptoms. Of these, 509 were actually suffering 
from disease of the bladder, while 154 had vesical symptoms due to some gynecolog'c disease. 

Another consideration is that important diagnostic 
information bearing on diseases of a purely genital char- 
acter may be obtained through the bladder, as, for 
example, the extent of a carcinoma and the signs of an 
impending or already existing rupture of an exudate. 

In order to solve the diagnostic problems which 
present themselves to the physician by reason of this 
close relation between the two systems and their special 
diseases, he is obliged to resort to cystoscopy in addition 
to the other methods of examination. No gynecologist 
is completely equipped for the practice of his specialty 
until he has mastered the cystoscope. For this reason 
I deem it necessary to describe in detail at this point 
the technique of cystoscopy and to discuss the indi- 
cations for its employment, reserving the pathologic 
results of the examination for the special portion of this 
work. I wish to emphasize, however, that proficiency 
in this method of examination can only be acquired in 
special courses of instruction. 

Nitze's cystoscope is employed. For the female 
bladder alone the modification of the instrument which 
I have devised will be found of advantage (Fig. 25). 
To correspond with the short female urethra I had Nitze's 
cystoscope reduced in length to 21 cm.; the advantage is that the 
shorter instrument is less likely to slip out of the bladder. I also 
flattened the angle of the tip which contains the lamp, 
so as to make it possible to obtain a better view of ^'^ oscope. 

the fundus without having to depress the handle of the instrument 
too much. As the female bladder is often greatly contracted, the move- 
ments of the male cystoscope, which is too sharply bent at the tip, are 
restricted. The source of light should be an accumulator. 

Cystoscopy may injure the patient by causing infection of the 
bladder, hence the most painstaking asepsis is necessary. The instru- 



FiG. 25. — Modi- 
pied NiTZE Cy.sto- 
SCOPE. Yi. (Origi- 
nal.) 



54 



GYNECOLOGICAL DIAGNOSIS 



Asepsis. 



ments cannot be disinfected by boiling because the water would destroy 
the lenses. Superheated steam is also injurious if used for any length 
of time, and this method of sterilization should therefore 
be employed only after the instrument has been used for 
examining infectious cases, as, for example, tuberculous patients, when 
absolute disinfection is imperative. For ordinary use a sufficient degree 
of asepsis can be obtained by keeping the instrument immersed in a 
3-per-cent. solution of carbolic acid. If the cystoscope is used daily, 

and several times a day, it should be kept con- 
stantly in tall glasses filled with a 3-per-cent. 
carbolic acid solution (Fig. 26). Immediately 
before the instrument is used, the part which is 
introduced into the bladder should be once more 
thoroughly rubbed with the same solution. The 
lenses resist continuous immersion in fluid for a 
long time. Casper prefers to dispense with the 
protracted use of disinfectants because they injure 
the instrument, and cleanses it merely by briskly 
and thoroughly rubbing it from time to time 
with cotton dipped in tincture of green soap. 
Stockel recommends that the cystoscope be kept 
in an atmosphere of formalin vapor, generated by 
placing formalin tablets in vessels devised by 
Nitze for the reception of the instrument. 

The introduction of germs from the patient's 
mucous membrane is avoided by thoroughly 
scrubbing the urethral orifice with a disinfectant. 
The urethra itself does not usually need to be 
cleansed. Gonorrhea of the urethra is an abso- 
lute contraindication to cystoscopy. In the 
chronic stage, when there is but little discharge, 
there is no objection to this investigation provided 
the patient has previously urinated. As in spite of every precaution it 
is not always possible to prevent the entrance of micro-organisms, the 
water should be drawn off immediately after the cystoscopic examin- 
ation has been completed, or the bladder may be irrigated with a 
3-per-cent. boric acid solution. The danger of infection is increased 
by mechanical injury of the vesical mucous membrane, and by leaving 
the instrument in the bladder too long. The examination should 
therefore be carried out cautiously and rapidly. In the hands of a 
practised cystoscopist infection is rare. 

In performing cystoscopy the woman is placed on the examining- 
chair in such a way that the genitalia are just on a level with the exam- 




FiG. 20. — Cystoscope in 
Carbolic acid Solution as 
IT Should be Kept When 
IT IS IN Const.^nt Use. 
(Original.) 



METHODS OF EXAMINATION 55 

iner's eye. The urine is then drawn off with a catheter and, if it is 
clear, the examination may be made at once. If it is turbid, the 
bladder must be irrigated with a 3-per-cent. boric acid 

° ^ . Technique. 

solution until the fluid returns absolutely clear. During the 
examination the bladder must be filled with about 200 grams (6 ounces) 
of a 3-per-cent. boric acid solution. After lubricating the tip with 
glycerin, the cystoscope is introduced slowly into the urethra and carried 
back into the bladder; the circuit is then closed. By turning the cysto- 
scope the light is thrown successively on the fundus, the upper wall, 
and finally the anterior and lateral walls of the bladder. (Space forbids 
more than a short description of the cystoscope in this place, and the 
reader is referred for further details to the special text-book by Nitze 
and Casper, and especially to Stockel's "Cystoskopie des Gynakologen.") 

Cystoscopy in the female differs from the same procedure in the 
male in certain very important respects, owing to differences in the shape 
of the bladder and its relations with the adjoining genital organs. The 
male bladder owing to its spherical shape is very well adapted for cysto- 
scopy; the female bladder, on the other hand, is flattened at the base, 
particularly from before backward, while the upper wall is superimposed 
on the lower wall like a dish, so that the two walls form a fairly acute 
angle with one another. If, in addition, the uterus lies on the bladder, 
the fluid injected into the viscus usually settles in the lateral portions, 
and it requires great distention to produce the desired spherical shape 
and to elevate the uterus. The cystoscope is therefore forced to adapt 
itself to the flattened shape of the bladder, and illumination of the 
sacculations and pockets of the organ can only be achieved by constantly 
moving the instrument about. Under ordinary conditions the diffi- 
culties are not excessive; but they are considerably increased, and 
often become insurmountable, if the bladder is dislocated by displace- 
ments of the uterus, tumors of the uterus and adnexa, and particularly 
by tumors developing in the cervix or vagina. The latter push the 
fundus of the bladder forward so that, even when the handle of the 
instrument is depressed as far as it can be, it is barely possible to obtain 
a view of the fundus and the orifices of the ureters. Dislocation of the 
fundus of the bladder and of the ureteral openings is the main difiiculty 
experienced in performing cystoscopy in the female. 

An excellent auxiliary method for ascertaining the secretory activ- 
ity of the kidneys and functional condition and permeability of the 
ureters is found in chromo-cystoscopy, as devised by Volcker and 
Joseph. The principle of the method consists in rendering chromo- 

the stream of urine visible by means of indigo-carmine. cystoscopy. 
An injection of 4 c.c. (1 fluidrachm) of a sterile, 4-per-cent. solution of 
indigo-carmine is made in the gluteal region about twenty minutes 



56 GYNECOLOGICAL DIAGNOSIS 

before cystoscopy is performed. The urine, which is stained blue, is 
then readily seen as it flows out of the ureters, so that the position of 
the ureteral openings is easily found, the activity of the ureters can be 
determined, and closure of the canals, or the presence of fistulae readily 
diagnosed. Chromo-cystoscopy is destined to render catheterization 
of the ureters superfluous in many cases. 

Cystoscopy will always be a method of examination fraught with 
discomfort to the patient and, in spite of all precaution, with danger as 
well. It should therefore not be employed in every case that presents 
vesical symptoms, but only when they are not sufficiently explained by 
simple methods of examination of the urine, and cannot be ascribed to 
conditions found in the genitalia. Cystoscopy is necessary in the fol- 
lowing conditions: 

1. In certain forms of catarrh of the bladder: thus, in long-pro- 
tracted and severe catarrh; in catarrh associated with intense symptoms, 
when the urinary findings are inconsiderable, in order to determine the 

character of the process and the degree of alteration in 
the vesical wall. Cystoscopy is indispensable also when 
there is reason to suspect, as the primary cause of the catarrh, tumors, 
stones, foreign bodies, or ulcerative processes. In acute catarrh cysto- 
scopy should not be employed. 

2. If there is pyuria, cystoscopy is necessary in order to decide 
whether it comes only from the bladder wall or from diverticula, 
perforated abscesses or pyosalpinx; or whether it is derived from the 
ureters or the kidneys. 

3. Hematuria, except in cases of slight hemorrhage with acute or 
gonorrheal cystitis, always calls for a cystoscopic examination, particu- 
larly if the amount of blood is large, or the hemorrhage is protracted,, 
or frequently repeated. The main point to determine is whether the 
blood comes from the bladder or from the kidneys. As hemorrhage from 
the bladder interferes very much with cystoscopy, while bleeding from 
the kidney demands an examination before the hemorrhage has ceased, 
the cystoscope should be introduced at once during the continuance of 
the hemorrhage in' order not to waste time, and th^ examiner should 
determine whether there are changes in the vesical wall, or the blood 
comes from one of the ureters. If the former is the case, an accurate 
diagnosis of the changes present must be postponed until the examina- 
tion has been repeated during the interval between the hemorrhages. 

4. When the history of the case, the examination of the urine, and 
the palpatory findings point to tumors, stones, or foreign bodies 
in the bladder. 

5. When vesical symptoms cannot be explained either by the 
examination of the urine or by the conditions found in the genitalia. 



METHODS OF EXAMINATION 



57 



6. For the diagnosis of certain changes in the genital organs 
which cannot be recognized by combined examination, — such as the 
extent of a carcinoma, impending or existing perforation of exudates, 
pyosalpinx, dermoid tumors, extra-uterine pregnancies; displacement due 
to myomata and other tumors; localization of genital fistulse. 

7. For the diagnosis of diseases, fistulae and occlu- 
sion of the ureters. 

8. For the diagnosis of 
functional disturbances 
and diseases of the 
kidneys. 

Catheterization of the Ure= 
ters is a method of exami- 
nation which the gynecologist 
is also occasionally obliged 
to perform if he wishes to 
retain complete control of his 
specialty without any outside 

Catheterization aSSlStaUCC. 1 llC 

of the Ureters. ^^g^ instrument 
for the purpose is Casper's 
ureter -cystoscope (Fig. 27). 
This is a cystoscope with an 
upper, semicylindrical groove, 
which is covered by the slid- 
ing semicylinders that act 
as carriers of the ureteral 
catheter. The funnel-shaped 
eye-piece is cut out so as to 
permit the catheter to be in- 
troduced in the proper direc- 
tion; the handle, which is 
attached to the catheter, 
pushes it forward and draws it back, thus giving the catheter the 
necessary curvature for effecting an entrance into the ureter. For 
the purpose of simultaneous catheterization of both ureters double- 
barreled metal tubes have been devised which hold two catheters at 
the same time. The two principal features of Casper's ureteral 
cystoscope are that the curve of the catheter can be regulated and 
that the catheter canal can be converted into a groove by means of 
a removable cover. 

The ureteral cystoscope is disinfected in the same way as the 
ordinary cystoscope. The metal tubes that carry the catheter may be 




Fig. 27. — Casper's Ureteral Cystoscope. (Newest model.) 



58 GYNECOLOGICAL DIAGNOSIS 

boiled. The catheters themselves are completely wrapped in cotton 
and sterilized by an exposure of three-quarters of an hour to super- 
heated steam. 

Catheterization of the ureters is not a difficult procedure in the 
hands of ,a practised cystoscopist. An absolute prerequisite, of course, 
is a clear view of the ureteral openings. If they are hidden 
in folds of the mucous membrane, or are unusually small, 
they are difficult to find. In the female catheterization of 
the ureters is rendered difficult and not infrequently impossible when 
the fundus of the bladder is displaced greatly by the traction of a dis- 
placed uterus, or the encroachment of tumors of the uterus or adnexa. 
Sometimes the finding of the ureteral openings may be assisted by 
grasping the anterior vault of the vagina with a tenaculum and drawing 
the fundus of the bladder in various directions. The cystoscope is 
introduced into the bladder with the catheter completely concealed, 
and the opening of the ureter to be catheterized is found. By elevating 
the funnel end, and at the same time carrying it to the opposite side, 
the tip is brought as near as possible to the ureteral opening and, as 
soon as it is directly opposite, the catheter is gently pushed in. By 
elevation, depression, and lateral movements of the handle, the tip of 
the catheter is guided into the ureteral opening and, as soon as this is 
passed, the catheter is cautiously carried upward in the direction of 
the ureter. If the catheter is to be allowed to remain, the cover and 
metal tube are withdrawn, leaving it free, and the cystoscope is removed. 
(For further details see Casper and Stockel.) 

Catheterization of the ureters adds to the ordinary dangers of 
cystoscopy the special danger of injury to the mucous membrane and 
infection of the ureter or pelvis of the kidney, especially when the blad- 
der is diseased. Although traumatism may be avoided by care and 
practice, and the danger of infection minimized by the most scrupulous 
attention to asepsis and thorough disinfection of the diseased bladder, 
the use of the catheter should nevertheless be kept within narrow bounds. 
Since chromo-cystoscopy has still further diminished the indications 
for its employment, catheterization of the ureters has become practically 
unnecessary for purely gynecologic purposes. It is only employed: 

1. In order to obtain the secretion of one kidney. 

2. When chromo-cystoscopy has failed to yield positive 
information as to the permeability and functional state of the ureter. 

3. In a few cases in order to mark the position of the ureter for 
operations in its immediate neighborhood (ordinarily the ureter is 
sufficiently marked without a catheter). 

[While the Nitze and Casper cystoscopes, as modified by several 
American gynecologists and surgeons, are in popular vogue for vesical 



METHODS OF EXAMINATION 



59 



examinations and catheterization of the ureters in this country, and for 
ordinary examinations are very effective, nevertheless every gynecologist 
should be familiar with the Kelly method of cystoscopy. Although the 
knee-chest position may be objectionable as well as tiresome to the 
patient, and likewise may be fatiguing to the examiner, nevertheless in 
many instances this method alone is advisable if the best results are to 
be obtained. For instance, the treatment of local conditions, such as a 
tuberculous ulcer, etc., can only be effected through the Kelly cystoscope. 
The following description of this method, as conducted by Kelly, has 
recently been given by Hunner in Kelly and Noble's "Gynecology and 
Abdominal Surgery." 



!JWIBWWIBWi«>J»wl»^^ 



Fig. 28. — The Type of Kelly Speculum now Most Used. 




"Postures of Patient. In using 
the Kelly cystoscope the patient may 
remain on her back, but in this case must 
have her hips elevated either by the use 
of sand-bags under the hips or by the 
use of the Trendelenburg elevated pelvic 
position. 

"An easier position and one in which 
the patient feels the least exposure, is 
Sims', or the semiprone. These positions 
have occasionally been used in Kelly's 
clinic since his early work on air disten- 
tion of the bladder, but experience has 

. shown that the posture most effective for 

the operator and applicable in nearly all 
cases is the knee-chest. The patient finds this position awkward at first, 
but with a little experience the posture is easily taken and maintained. 
"It is probable that most failures in cystoscopic work by use of the 
knee-chest method are due to the neglect of a few important and essential 
rules. The principle of this method is to obtain as great evisceration of 
the pelvis as possible. There should, therefore, be no band or binder 
of any sort constricting the upper abdomen. The patient should be in 
the knee-chest, not the knee-elbow position. The knees should be slightly 
anterior to a vertical line let fall from the hip-joint. The trunk muscles 
must be relaxed, giving the back a downward, rather than upward bow. 
"After incorrect posture of the patient, perhaps the most fertile 
source of embarrassment in this work is the failure to dilate either the 



60 



GYNECOLOGICAL DIAGNOSIS 



rectum or the vagina with air before dilatation of the bladder. If the 
bladder is first dilated, its distention takes place in the. direction of least 
resistance, which is towards the potentially empty pelvis, or, in other 
words, toward the base of the bladder. This carries the vesicovaginal 
septum upward, and with it the ureteral orifices are carried beyond the 
range of easy vision. On the other hand if the rectum or vagina, or 
both, are first allowed to fill with air, the vesicovaginal septum is ballooned 
ventrally, thus carrying the ureteral orifices downward. Now if the 
speculum is introduced in the bladder and this viscus is allowed to fill 
with air, the vesicovaginal septum is carried upward to a considerable 
degree, but usually it does not rise above a plane which is parallel with 

the plane of the table; in 
other words, the ureteral 
orifices are usually found 
on a level with, or even 
below the speculum when 
this is held in a horizontal 
position. 

"If the above simple 
but essential rules are ob- 
served, cystoscopy with 
the use of air distention of 
the bladder will be found 
to be a very easy 
method. There are minor 
points of technique which 
one learns by experience, 
and a few of them may 
be mentioned here. 
"It is not fair to the patient to keep her in position while one is 
taking his first lessons in the use of the head-mirror. The cystoscopist 
should become thoroughly familiar with the necessary instruments and 
the reflected light by working with an empty pasteboard box or other 
hollow structure before even attempting to examine a patient. 

"Technique of Cystoscopy. — Having made the general phys- 
ical examination and taken a culture from the urine, how shall we examine 
the new patient with the cystoscope? With a pipet cocain, in 5- or 
10-per-cent. solution, is introduced in the urethra and the patient is 
changed to the knee-chest position. By the time this position is taken 
the cocain has deadened the more acute sensibility of the urethra, and 
its external orifice can be stretched to the required size by means of 
the graduated cone dilator (Fig. 29). Occasionally the external 
urethral orifice is found to be 1 cm. in diameter, but it generally takes 




Fig. 29.- 



-DlLATING THE ExTERN.iL URETHRAL OrIFICE with 

the Graduated Cone Dilator. 



METHODS OF EXAMINATION 



61 



the cone dilator only to the 6 or 8 mm. mark, and must be considerably 
stretched before it will take the No. 10 (10 mm.) speculum. If done 
gently with a boring motion and with the cone well lubricated, this 




Fig. 30. — Median Section, Knee-chest Posture, showing the anatomic relations of the pelvic organs when 
the rectum, vagina, and bladder are dilated by atmospheric pressure. Also the curves of the urethra. (Kelly.) 

stretching can generally be carried to 10 mm., or even beyond, without 
pain to the patient, and without splitting the mucosa. If the external 
urethral orifice is unusually small, or if the surrounding tissues are 
indurated from previous vulvitis or urethritis, it may be necessary to 
use a No. 8 or No. 9 speculum for the first examination. One should make 



62 GYNECOLOGICAL DIAGNOSIS 

it a rule to avoid hurting the patient at the first examination. It is better 
to be satisfied with only partial examination for the first, and even for 
the second and third visit, provided the patient's confidence is gained. 

"It seems scarcely necessary to give directions for the insertion of 
the speculum. But the operator must bear in mind the anatomy of 
the urethra and follow its natural curves. The speculum is pointed 
slightly upward until it engages the external urethra, when its handle 
is elevated so as to direct the barrel downward over the symphysis 
pubis. On withdrawal of the obdurator the inrush of air into the 
bladder balloons the vesicovaginal wall upward, and if the handle 
of the speculum is dropped, its weight will bring the barrel of the 
speculum against the base of the bladder, and the speculum is found to 
take a position about horizontal. 

"The usual routine of the examination is, first, to sweep the speculum 
about the entire bladder, noting any mucous membrane changes; second, 
to examine the vertex carefully for the presence of stone or other foreign 
body; third, to examine the area immediately back of the symphysis, 
using the fingers of one hand when necessary to push up the abdominal 
wall in the suprapubic region; fourth, to carefully examine the trigonum 
and the regions of the ureteral orifices. If a trigonitis or ulceration of 
the trigonum be suspected, it is best to examine this region first, before 
it has been disturbed by manipulations of the speculum. If the symp- 
toms point to a urethritis, a small speculum should first be used and the 
urethra examined at once before it becomes hyperemic from massage by 
the speculum. 

"After one is familar with cystoscopy, the ureteral orifices can usually 
be located at once without following a definite rule; but for the beginner 
the directions laid down by Kelly should always be followed. After 
finishing the general examination of the bladder the speculum is with- 
drawn until the mucous membrane of the internal urethral orifice begins 
to close about the inner end of the speculum. The handle is then tilted 
upward and the speculum is pushed in toward the center of the bladder 
for a distance of about three centimeters. The handle is then depressed 
in order to bring the inner end of the speculum to a plane with the base 
of the bladder, and under guidance of vision the speculum is swept to 
the side until the ureteral orifice is located. This is usually in the arc 
of an angle of between 15 and 30 degrees from the mid-line. The left 
ureteral orifice should be sought first, for in the majority of cases it is 
more easily found, owing to the depression of the left vesicovaginal wall 
by the weight of the uterus and the cervix. For the same reason the 
left orifice is slightly nearer the internal urethral orifice than the right. 
The air-pressure carries the right orifice farther up toward the sacrum 
and flattens the mons ureteris of this side- 



METHODS OF EXAMINATION 68 

"When searching for the ureteral orifices the most helpful land- 
mark is the interureteric ridge. If, after following the above directions, 
the ureteral orifice is not found, one should not proceed in a hap-hazard 
manner to search for it, but should first orient himself with reference to 
known landmarks, such as the internal urethral orifice and interureteric 
ridge. If the inner end of the speculum is found to be resting on the 
ridge, the probabilities are that the speculum has been pushed in the 
bladder to the proper distance, and that the ureteral orifice will be found 
either laterally or medianward from the area first inspected. If the 
interureteric ridge is seen to lie at some distance beyond the end of the 
speculum, we know that the speculum has not been pushed far enough 
from the internal urethral orifice; whereas, if the ridge is nowhere in 
the field of vision, it is because the speculum has been pushed in too far. 
The experienced cystoscopist grasps these clues and readily corrects 
his first location; but for the beginner it is often a saving of time to 
withdraw the speculum to the internal urethral orifice and to again 
follow the prescribed routine." 

Hunner calls attention to a second riclge in the bladder, which 
has not been mentioned by cystoscopists, and which may readily confuse 
the beginner. He calls this the vesico-uterine fold, as it corresponds to 
the vesico-uterine sulcus outside of the bladder. It is a transverse ridge 
or fold of the bladder mucosa, situated about 3 cm. back and running 
parallel with the interureteric ridge. It is most marked in women 
who have borne children, and in some very relaxed cases there are one 
or two small accessory ridges running parallel with the main vesico- 
uterine fold. Frequently one is led to the exact location of the ureter 
by seeing a spurt of urine even though the speculum may be at some 
distance from the orifice. 

"The ureter generally enters the bladder on a papilla-like elevation 
of the mucosa, the so-called "mons ureteris." This, as already 
stated, is often more prominent on the left than on the right, and it is 
generally most developed in women who have borne children. In 
nulliparae the mons is frequently absent, and instead of an elevation of 
the mucosa there may be a saucer-like depression. When the ureter is 
shortened from any cause, especially in the inflammatory thickening 
of tuberculosis, the orifice may be retracted. At times one finds a vessel 
circumscribing the ureteral orifice, or one or more vessels may radiate 
from the orifice not unlike the retinal vessels about the optic disc. 

"Should the base of the bladder be the seat of inflammatory changes 
the ureteral orifice may be difficult to locate because of alteration in 
both the immediate and distant landmarks. One is sometimes 
compelled to hunt for the orifice with the ureteral searcher. The 
inflammatory swelling may interfere with the jet-like action of the urine; 



64 GYNECOLOGICAL DIAGNOSIS 

but with a little patient watching one can generally catch the light- 
reflection as the urine spreads over the mucosa, and in this manner the 
orifice may be located without the use of the searcher. To collect urine 
from a kidney when for any reason it is undesirable to catheterize the 
ureter, we make use of the cystoscope with oblique distal end, such as 
originally shaped by Grimfeld. This can be held to cover the ureteral 
orifice more easily than the cystoscope with the ordinary square end." 

Catheterization of the ureter is a simple matter after its 
orifice is located, and special rules are not necessary. If the hands are 
surgically clean, the renal catheter may be grasped at any portion; but 
if the hands are septic, the catheter must be grasped near its outer end 
at a point that is not to reach as far as the urethra with the catheter at 
full insertion. The renal end may be guided into the speculum by an 
assistant who handles it with sterile forceps. An assistant is not abso- 
lutely necessary, for the stilet stiffens the catheter sufficiently to enable 
the operator to handle it from the distal end. 

If one wishes to grasp the catheter near the speculum and still be 
certain of a good technique, a rubber glove for the thumb and first two 
fingers is easily slipped on, and by keeping this already sterilized, pow- 
dered, and wrapped in a sterile towel, the operator can first locate the 
ureteral orifice, and then have the assistant draw the glove over his 
catheter hand, either right or left. It is well always to wear the head 
mirror over the eye opposite the hand used in catheterizing, to avoid 
touching the mirror with the catheter as it is pushed past the operator's 
head. — Editor.] 

Bacteriologic Diagnosis. 

The purpose for which bacteriology is employed in gynecologic 
diagnosis is to demonstrate certain specific micro-organisms in the 
tissues or in the secretions of the diseased organs. The bacteriologic 
examination is usually made with a microscope, cultures being resorted 
to only in exceptional cases. 

Bacteriological methods of examination are employed under the 
following conditions : 

1. For the Diagnosis of Gonorrhea. The gonococcus is 
found in the secretions of the diseased mucous membrane and also 
penetrates its substance. In practice demonstration of the micro- 
organisms in the secretions by means of characteristic 

Gonorrhea. . . , , . ,^ . , . « 

stammg methods is sufficient; demonstration oi gonococci 
in the tissue is much less certain and, owing to the great danger of 
infection of the wound left by the excision, it is not to be recom- 
mended. A minute quantity of the secretion of the diseased membrane 
is obtained with the platinum loop and thinly spread on a cover- 
glass by drawing another cover-glass over it. The cover-slips are allowed 



METHODS OF EXAMINATION 



65 



to dry in the air and passed three times through the flame. The smear 
is stained with a watery solution of methylene blue, allowed to dry, and 
examined under the oil immersion lens. If many other bacteria are 
present, the Gram method of staining should be employed in order to 
differentiate the gonococci. This consists in placing the cover-slips 
in a solution of anilin water and gentian violet for half an hour, rinsing 
and staining for from three to five minutes in dilute Lugol solution 
(1 : 150), again rinsing in water, and placing the smears in absolute alcohol 
until they are completely decolorized. The gonococci are now com- 
pletely decolorized and may be counter-stained with Bismarck brown, 
so that they form a distinct contrast to the other organisms, which are 
stained a dark violet. 

Gonococci are diplococci which by division assume the shape of 
biscuits (rolls) or coffee beans; by further division groups of from 





Fig. 31. — Gonococci in Pus. (Original.) 



Fig. 32. — Tdbercle Bacilli in Sput0m. 
(Original.) 



twenty to thirty double individuals are formed. The cocci are found in 
the leukocytes, on squamous epithelial cells, or rarely free in the secre- 
tion (Fig. 31). The diagnosis is based on finding the gonococci within 
the cells and on the positive Gram. Diplococci lying outside of the cells 
are more difficult to identify, and still more so are the involution forms. 

Secretions which contain but few other bacteria, or none at all, 
are best adapted for the demonstration of gonococci. They are the 
secretion of the urethra and of the uterus, especially when the external 
OS is contracted. Gonococci are most easily found in the vulvo- 
vaginitis of children before any treatment has been given. The vaginal 
secretion of adult women is useless for the purpose of demonstrating 
gonococci. Cultures are not employed for the diagnosis of gonorrhea. 

2. For the Diagnosis of Tuberculosis: — A 
bacteriologic diagnosis of tuberculosis can be made by 
demonstrating the tubercle bacilli, by making cultures, and by 
positive inoculation experiments. 

5 



Tuberculosis. 



66 GYNECOLOGICAL DIAGNOSIS 

The tubercle bacillus dwells chiefly in the diseased tissues, while 
it appears to be destroyed in a short time by the secretions of the genital 
organs. Occasionally it can be demonstrated with the microscope in 
the discharge from suspicious looking ulcers, in the secretion of the dis- 
eased uterus, and in the urine in tuberculosis of the bladder and kidneys. 

The tubercle bacillus is identified by its characteristic shape and 
specific staining properties. The secretion to be examined is thinly 
spread on a cover-slip with the platinum loop, dried in the air, and 
fixed by passing it three times through the flame. The preparation is 
then covered with an excess of concentrated Ziehl's solution (1 gram of 
fuchsin in 10 grams of absolute alcohol and 100 grams of 5-per-cent. 
watery solution of carbolic acid) and slowly allowed to dry over the 
flame. The stain is then washed oft" with water, the smear decolorized 
in a 2. 5-per-cent. nitric acid solution and, after thoroughly shaking in 
60-per-cent. alcohol and again rinsing in water, counter-stained for one 
minute with a dilute watery solution of methylene blue. With an 
oil immersion lens the characteristic shape and intense red color of 
the tubercle bacilli, in contrast to the blue surroundings, are readily 
recognized (Fig. 32). 

As tubercle bacilli very often do not remain long in the secretion, 
or are destroyed by the rapid growth of other bacteria, their absence 
is never to be taken as a proof of the absence of 
tuberculosis. 

More positive information is afforded by examination of the 
tissue , because along with the bacillus itself the specific tissue reaction 
may be demonstrated. The following method of staining the sections, 
recommended by Cornet, is the most satisfactory. The sections are 
placed in a small dish containing Ziehl's solution and exposed for from 
one to twelve hours in a thermostat at a temperature of 37° C. They 
are then transferred to water, placed for an instant in 2. 5-per-cent. 
nitric acid solution, and then in 60-per-cent. alcohol, which is repeatedly 
renewed. After thoroughly rinsing the sections in water, they are 
counter-stained with a watery solution of methylene blue and examined 
under the oil immersion lens. Even if the bacilli are present in such 
small numbers that they are not found, the characteristic tissue reaction 
may be recognized with this method of staining. The necessary tissue 
for the examination is obtained from the uterine cavity by an exploratory 
curettage or by excising suspicious looking ulcers of the vagina, the 
vaginal portion and vulva. 

Making cultures is a difficult and time-consuming procedure, 
and is hardly applicable in ordinary practice; the same is true of 
inoculation, and these methods are practically employed only in very 
important cases which cannot be cleared up by simpler methods. 



METHODS OF EXAMINATION 



67 



3. For the Demonstration of Pyogenic Microorgan- 
isms. Examination for pyogenic microorganisms, streptococci and 
staphylococci, is of importance in the differential diagnosis from gonorrhea 
and tuberculosis as causes of suppuration, and for the Pyogenic 

prognosis, in order to determine the virulence of the process. Microorganisms. 
The pus which is to be examined for these microorganisms is almost 
without exception derived from the adnexa, and is obtained by means 
of an exploratory puncture of abscesses, of pyosalpinx through the 
vagina, or by opening them in the course of operation. The object of 
the examination is to establish the prognosis of an operation in time, 
or to enable the operator to adapt his procedures to the kind of micro- 
organism found. Free suppuration from the uterus, or a perforated 
abscess or pyosalpinx, interferes with the finding of the specific pyogenic 
microorganism because of the large numbers of saprophytes present. 





Fig. 33. — Streptococci in Pns. 
(Original.) 



Fig. 34. — Staphylococci in Pus. 
(Original.) 



For a microscopic examination a droplet of pus is obtained 
with the platinum loop at the time the abscess is opened, spread between 
two cover-slips, dried in the air, and stained with methylene blue. 
Streptococci (Fig. 33) appear in the pus usually as short chains of two 
to three individuals. Staphylococci are congregated in small groups 
of from three to ten (Fig. 34). The microscopic examination, however, 
frequently proves negative because the specific organisms are not 
sufficiently numerous to be demonstrable, or cannot be positively differ- 
entiated from other germs because they possess no specific tinctorial 
properties. 

The more reliable method of identification is by means of c u 1 1 u re s , 
which should always be employed if the diagnosis can wait a day or 
two. The simplest procedure consists in making a streak culture of 
pus on a slanting agar tube under aseptic precautions. After twenty- 
four to thirty-six hours' exposure in a thermostat a positive diagnosis 
can be made. If there is reason to believe that the organisms are few 



68 GYNECOLOGICAL DIAGNOSIS 

in number, a preliminary culture should be made in sterile bouillon. 
After the medium has become distinctly turbid, a second examination 
is made with the microscope and with an agar tube, and a diagnosis is 
arrived at without difficulty. 

The virulence of a suppurative process is best determined by 
intraperitoneal inoculation of white mice. 

Bacterium coli, Pneumococcus, and Actinomyces rarely 
need to be demonstrated for a gynecologic diagnosis. 

Radiography. 

Examination by means of the Rontgen rays, which is employed as 
a supplementary diagnostic method in almost every branch of clinical 
medicine and has produced some radical changes in these methods, has 
added very little to gynecologic diagnosis. Our methods of investi- 
gation, especially combined palpation, are so complete that we rarely 
have occasion to clear up a doubtful condition by means of the Rontgen 
rays; and, on the other hand, the genitalia are so hidden in the pelvis, 
and the differences in the resistance which they offer to the passage of 
the rays are so slight, that we can rarely hope to obtain a satisfactory 
X-ray picture. It is only when the tissues to be investigated offer great 
resistance to the passage of the rays that a fairly distinct picture can 
be obtained; as, for example, in the case of the bones of an almost 
mature fetus; bones, teeth and calcareous plates in dermoid tumors 
and teratomata; the presence of calcification in fibromata and extra- 
uterine pregnancies; stones in the bladder, ureter and uterus; metal 
foreign bodies in the bladder and uterus. The technical difficulties are 
so great, however, that a diagnosis is possible only in exceptional and 
very suitable cases. The most promising field of radiography is the 
detection of foreign bodies (especially hair-pins) and vesical calculi, 
in which some noteworthy results have already been recorded. 

[X-ray laboratories, in which physicians can take advantage of the 
use of radiography, are to be found in almost all large cities. — Editor.] 

The Making of a Gynecologic Diagnosis. 

There are two methods of making a diagnosis: the objective exam- 
ination of the patient and the history. The latter is the older method 
and was formerly the only one at the physician's disposal. At the 
present time it still plays an important part among the older physicians, 
and in the hands of attentive observers and experienced practitioners 
gives very good results. During the past decades this method of diag- 
nosis has been crowded into the background by direct examination of 
the diseased organs. Our methods of examination are in constant 
process of development, and in certain branches have reached such a 



METHODS OF EXAMINATION 69 

degree of delicacy that a positive diagnosis can be made without any 
interrogation of the patient whatever. The comparative importance 
of the two diagnostic methods varies in the different specialties and 
depends in general on the perfection of physical methods of examination. 
Ophthalmology, laryngology, and certain branches of internal medicine 
have the most accurate methods of examination; while other branches, 
such as psychiatry, are almost entirely dependent on the anamnesis. 

Gynecology is one of the specialties which enjoys the advantage 
of very delicate methods of examination, and it owes the prominent 
position which it occupies at the present day most of all to the develop- 
ment of the combined examination. In the majority of cases a 
positive diagnosis can be made by combined examination 
without any aid from the history, and it should there- 
fore occupy the first place in the construction of the diag- 
nosis. Gynecologic diagnosis practically means the recognition of 
a disease of the genital organs from the results of combined examina- 
tion. The physician's duty is double : to feel the changes and to interpret 
them correctly. The first is a matter of practice, which can only be 
acquired in special touch-courses and retained in one's subsequent 
practice. Without this constant subsequent practice the gynecologist 
will soon find that he has lost his touch, and with it the foundation of 
gynecologic diagnosis. The interpretation of the findings, on the other 
hand, is a matter of experience, and can be acquired only by constant 
opportunities to verify one's diagnoses. It is only since inspection of 
the diseased organs in the living subject at laparotomies has made this 
possible that gynecologic diagnosis began to make rapid strides; and 
it is now gaining in accuracy every year. Every gynecologist repeats 
in his own work the process of evolution of the signs of gynecology in 
general; for the more he operates, the greater will be his diagnostic 
skill. This avenue is closed to the general practitioner, and without the 
assistance of his teachers' experience he would never achieve the ability 
to make a positive diagnosis. This experience gives him the correct 
interpretation of his findings, and with it as a foundation he is enabled 
to develop himself in his daily practice. For this reason thorough 
instruction in gynecologic diagnosis by special touch-courses is absolutely 
necessary; but it must be accompanied and later supplemented in daily 
practice by the written page, and this is the real justifica- 
tion of this text -book of mine. , 

The interpretation of the findings should be as precise as possible 
and should represent a clearly circumscribed pathologic 
conception. The physician must recognize a well characterized disease, 
and not rest content merely with determining the conditions present, 
or with a general confused mental picture of mere symptoms. Too often 



70 GYNECOLOGICAL DIAGNOSIS 

the physician is satisfied if lie feels a tumor, and makes no attempt, 
by more careful examination, to determine the nature of the tumor; 
or he dismisses his patient with a diagnosis of flooding, dysmenorrhea, 
menorrhagia and the like. These are mere symptoms and in no sense 
diseases,' and such a diagnosis can only be followed by symptomatic 
treatment. In my teaching I have always endeavored to train my 
students in such a way as to make them diagnosticate a clearly defined 
pathologic condition, and I shall follow the same method in the section 
on special diagnosis. 

It appears then that gynecologic diagnosis demands first 
of all a local examination. The physician must never allow per- 
sonal considerations to interfere with such an examination, nor permit 
himself to be deterred by the patient, who will often try in every possible 
way to escape the much dreaded ordeal. A delayed examination 
in the case of uterine cancer, for example, may, by postponing the 
diagnosis, sacrifice the patient's life. There are few cases in gynecology 
in which the objective examination cannot be made the basis of the diag- 
nosis; they are chiefly in young and unmarried women, and those who 
are excessively nervous and irritable. In such cases internal examina- 
tion should if possible be dispensed with, because the psychic, nervous, 
and occasionally moral injury is greater than the advantage gained by 
a strictly objective diagnosis. Examination in such cases must be 
replaced by the anamnesis; if this gives no result, or the patient's state- 
ments point to a severe or a local trouble, demanding local treatment, 
an examination becomes imperative and should then be performed under 
anesthesia, which removes the above mentioned disadvantages of the 
examination and makes it much less difficult. 

Anamnesis. Next to the objective examination, the interrogation 
of the patient for the purpose of ascertaining the symptoms has a 
certain importance for the diagnosis; but the symptoms should be 
utilized for making the diagnosis only when the objective 
examination fails to yield the desired result. For this 
reason the physician who is not perfectly sure of his ability to make 
an examination is constantly tempted to resort to the auxiliary 
method, and occasionally constructs from the symptoms a diagnosis 
which has no objective background whatever; whereas the practised 
diagnostician relies less on the symptoms the more confidence he 
feels in his examination. Nevertheless the symptoms cannot be 
dispensed with altogether in making the diagnosis, particularly in the 
recognition of those diseases in which the palpatory findings are 
uncertain or absent, such, for example, as endometritis; or when the 
objective findings are not sufficiently clear, as in extra-uterine pregnancy; 
or when the conditions found in different diseases are apt to be very 



METHODS OF EXAMINATION 71 

similar. The value of the information derived from the symptoms, 
however, is never very great, because gynecologic symptoms are all 
very much alike. Sensations complained of by the patient practically 
always follow the same direction: they complain of pain, hemorrhage, 
discharge, and a few other less important symptoms; hence it is not 
easy for the general practitioner to construct a picture of the disease 
from the symptoms. Not so, however, with the experienced gynecologist. 
He soon learns to distinguish between the sacral pain complained of 
in retroflexion of the uterus or posterior parametritis. He very soon 
learns, too, the diagnostic significance of the character of the different 
kinds of dysmenorrhea; not infrequently the character of the hemor- 
rhages enables him to recognize the disease, so that, conversely, the cases 
are by no means rare in which he is able to make a diagnosis from the 
woman's statements without examining her. The general practitioner 
can hardly hope to attain such a degree of proficiency, and he is there- 
fore earnestly warned not to attempt such methods, as they frequently 
lead to a mistaken diagnosis. 

On the other hand, the symptoms complained of by the patient 
unquestionably assume much greater importance vv'hen it becomes 
necessary to bring them in accord with the genital disease 
which has been diagnosticated by means of an objective 
examination. A diagnosis cannot be called exhaustive or complete 
unless all the symptoms complained of can be readily explained by the 
local disease; if they are not fully explained, it must be assumed that 
the affection which has been demonstrated is not the only disease 
present, or that it represents merely a comparatively indifferent second- 
ary condition. This may be explained by an illustration: Suppose 
the phA^-sician has demonstrated by means of a combined examination 
enlargement of the uterus to the size of a fist from the presence of 
interstitial myoma, and the patient complains only of profuse menstrua- 
tion coming on ahead of time, with intense dysmenorrhea before and 
during the bleeding; the symptoms can be referred to the myoma and 
the case is clear. But suppose the woman complains in addition of 
constant dragging and burning pain in the left side of the abdomen, 
especially while walking, during physical labor, or sexual intercourse. 
In such a case there is a strong probability that there are, in addition, 
inflammatory foci in the left parametrium or in the adnexa, and the 
presence of such foci must therefore be determined by an examination. 
It happens quite frequently that symptoms referable to disease of the 
liver, stomach or kidney are commingled with the symptoms of 
disease of the lower abdomen and complicate the clinical picture. 
For this purpose an objective examination to explain the symptoms 
cannot be too minute. 



72 GYNECOLOGICAL DIAGNOSIS 

Finally, an accurate knowledge of the symptoms may be necessary 
in many cases in order to form a basis for the treatment, particu- 
larly when the symptoms cannot be removed by radical treatment of 
the disease. 

In addition to the symptoms the etiology of the disease and 
its previous course must receive attention in taking the history. 

The general practitioner is usually not inclined to attach much 
weight to this portion of the anamnesis; he contents himself with the 
diagnosis and treats the patient accordingly. AVhile it is true that it 
chiefly affects the scientific aspect of the case, nevertheless valuable 
information for the prognosis and treatment of the case is quite often 
gained by careful attention to these points. For example, it is not 
immaterial whether in the course of a tubal tumor there have been 
several attacks of peritonitis, whether a parametritic exudate is puer- 
peral or due to gonorrhea — and these facts can be determined only by the 
anamnesis. An attempt should be made in taking the history to deter- 
mine the time when the symptoms began and to find an intelligible 
cause. The causes of gynecologic affections are found principally in 
confinements, the puerperium, injuries sustained during menstruation, 
sexual infection, and occasionally in the mode of life, occupation, and 
domestic surroundings. Sometimes, depending on the special character 
of the disease, the physician may be called upon to invade c^uite different 
fields in his investigations. Questions in regard to the family history 
are practically never necessary, and the history during childhood is very 
rarely required. It is also usually superfluous to ascertain in every case 
the character of the menstruation, the histories of previous confinements 
or even of some internal disease which the patient may have had in earlier 
life, unless the gynecologic disease has its origin in such a condition, in 
which case the connection must be established as clearly as possible. 

It follows from what has been said that interrogation of the patient, 
while it has but limited importance in making the diagnosis, never- 
theless plays a very important part in enabling the physician to form 
Technique of ^ gcncral idea of the character of the disease. For this 
History-taking, ppagon it docs not seem to me superfluous to touch upon 
certain points which may materially change the value of the data 
obtained from the history. To begin with, it is almost needless to say that 
we are obliged to touch upon a number of points of a very delicate nature. 
The woman's native modesty will in most cases keep her from volun- 
teering information on matters which belong to married life and sexual 
intercourse; but the physician cannot always avoid mentioning such 
points, and in doing so, he should therefore spare the woman's feelings 
as much as possible. We must constantly bear in mind the possible 
effect of our questions if we wish to avoid arousing the woman's sus- 



METHODS OF EXAMINATION 73 

picion and producing a condition of psychic unrest. It is incredible 
what a variety of meanings an anxious patient may discover in the 
simplest question put by the physician. We must also be constantly 
on the lookout for deception on the part of the patient, intentional or 
unintentional, in order to avoid being led astray. As we are obliged in 
our specialty to uncover both marital and non-marital sins, we do not 
often obtain truthful information on these points. It must also be 
remembered that a careless word on the part of the physician in regard 
to infection may undermine the happiness of a household. The rock 
on which the anamnesis is most frequently wrecked is the character 
of the woman herself. Woman 'is such a vacillating creature, influ- 
enced by all kinds of external impressions, so much dependent on feel- 
ing and caprice, that she is frequently unable to give a clear account 
of anything. In many women the physician's questions produce such 
a degree of excitement that they are hardly able to speak, let alone 
give correct answers. Women as a rule are not much given to precise 
utterance and still less to accurate self-observation. On the other 
hand, many women are endowed with such an excess of feeling that we 
must be on our guard not to mistake their sensations for symptoms. 
The physician must make due allowance for these feminine character- 
istics. Fortunately it is possible to influence them in a very marked 
degree. A short, brisk manner intimidates the patient and excites her; 
restlessness and nervousness on the part of the physician are at once 
communicated to the patient; while, on the other hand, an equable 
and amiable manner tends to quiet her agitation. By persistent interro- 
gation one can always succeed in getting the woman to answer in the 
manner desired. Taking everything into consideration, it is therefore 
no easy matter to obtain a satisfactory history. I have always found 
it better not to ask too many questions, because a woman is always 
tempted to give the answers that the doctor appears to expect. It is 
better to let her tell her own story. An experienced practitioner can 
glean what he needs from the patient's statements; if she digresses 
she must be brought back to the point. While listening to her story 
one has an opportunity to form an idea of the patient's character and 
of the psychic and nervous condition. — Finally, the question when 
the history should be taken remains to be considered. In general it 
should precede the examination as in other departments of medicine, 
and for the general practitioner this method is necessary, if only to 
enable him to recognize the case as a gynecologic one. But even the 
specialist will find it better to begin by taking the history, so as to quiet 
the patient by conversation and learn what direction his examination 
should take; otherwise he may be obliged, much to his discomfiture, 
to begin all over again. As female patients often have the unpleasant 



74 GYNECOLOGICAL DL\GNOSIS 

habit of forgetting or concealing the most important points, the phy- 
sician should first direct his questions to the function of the chief organs. 
During the examination the findings will suggest other questions and, 
after the examination has been completed, the case can be cleared 
up in every direction by completing the histor3^ 

Observation of the Patient. Not infrec^uently the practitioner will 
be unable, in spite of all diagnostic methods and of a carefully taken 
history, to arrive at a definite diagnosis. Unless he prefers to seek the 
Observation of assistaucc of a uiorc experienced adviser at once, this 
the Patient. ^^.^j force him to keep the patient under further observa- 
tion, and to content himself for the time being with expectant treatment. 
Subsequent observation brings with it repeated examinations and thus 
the case is frequently cleared up. A more important point, however, 
is that changes sometimes develop in the disease in the course of time 
which help to explain findings that were previously doubtful. For 
example, it is often very difficult to make a differential diagnosis between 
a myoma and an intra-^ligamentary exudate. Keeping the patient under 
observation for a few weeks will suffice to bring out changes in the 
consistency and shape of the tumor due to absorption, and the diagnosis 
of an exudate is no longer doubtful. An important point to bear in 
mind in keeping the patient under observation is that she shall not 
suffer any injury through postponing the diagnosis. Observation, for 
diagnostic purposes, of cases that suggest malignancy, 
whether at the cervix or in the abdomen, is not permis- 
sible. Formerly it was a well recognized practice to keep a suspicious 
ulcer in the vaginal portion, for example, under observation. The obser- 
vation was continued until malignant degeneration was definitely deter- 
mined. Nowadays this is a technical error, because the delay renders 
the carcinoma inoperable. If there is the slightest suspicion of malig- 
nancy, other means must be employed to arrive at an immediate diag- 
nosis. With the exception of these cases, very good diagnostic results 
are often obtained by keeping the patient under observation. In inflam- 
matory diseases absorption brings about characteristic changes in the 
shape and consistency of the mass; in the case of doubtful tumors 
of the adnexa observation in time^demonstrates that the tube forms the 
nucleus of the tumor. In small ovarian tumors the subsequent growth 
frequently decides between retention-cyst and neoplasm; in extra- 
uterine pregnancy weeks are often required to clear up the question 
whether the gestation-sac is Mill growing or the ovum has already 
perished; in doubtful cases of intra-uterine pregnancy the diagnosis is 
often confirmed only by continued observation; and, finally, in preg- 
nancy with a dead fetus, subsequent observation of the uterus is the 
only means of arriving at an absolutely definite diagnosis. Observa- 



METHODS OF EXAMINATION 75 

tion of the patient is occasionally combined with certain methods of 
treatment which lead to a diagnosis ex juvantibus, such as absorb- 
ent treatment of inflammations and antisyphilitic treatment in cases of 
doubtful processes on the vulva. 

The General Condition. Gynecologic diseases are in the main 
local in character and represent local reactions to irritants which affect 
the genitalia during parturition or during menstruation as a result of 
infection, etc. The diagnosis accordingly is in General 

most cases confined to local changes. Not infre- condition, 

quently, however, gynecologic symptoms develop in the course of 
general diseases and owe their existence to the general disease and not 
to a local affection; as, for example, pruritus in diabetes; menorrhagia 
in diseases of the heart, kidneys, and blood; flooding in chlorosis; 
amenorrhea in tuberculosis. In such cases the physician is consulted 
on account of the gynecologic trouble, and this leads him to discover 
the general disease. If no other local cause can be found for a gyne- 
cologic symptom, a general disease must be looked for. 

The patient's general condition, however, is of even greater impor- 
tance for determining the effects of the local abdominal disease on remote 
organs and on the entire organism. Such sequela? are so frequent in 
women, and often so severe that the physician is bound not 
to neglect them. Examples are the general anemia which occurs in 
endometritis, uterine cancer with hemorrhages, and in severe catarrh; 
chronic toxic states, manifesting themselves as general weakness and 
loss of nutrition, which follow diseases that lead to the formation of 
toxins, such as carcinoma, pyosalpinx, purulent exudates, infectious 
purulent catarrh, and the like. Whenever the case at the first glance 
does not declare itself as a purely local process, the patient must be 
interrogated concerning the functions of the vital organs — heart, stom- 
ach, intestines — and if any symptoms referable to these organs are 
complained of, they must be subjected to a thorough examination. In 
most cases when distant organs and the general condition are affected, 
it is clue to nervous influences; and it is not always easy to discover in 
these cases the connection with the local abdominal disease. Still less 
clear is the connection with gynecologic;. diseases in the case of general 
nervous conditions such as neurasthenia, hysteria, and psychoses. In 
any case the greatest conservatism in this respect is to be recommended, 
because the treatment of a gynecologic affection, under the false impres- 
sion that it is associated with a neurosis, may do a great deal of harm. 



special Diagnosis. 



The Normal Findings. 

Before beginning the special diagnosis of gynecologic diseases, 
the normal findings will be described because they must form the founda- 
tion for the interpretation of pathologic conditions in the female genital 
organs — the topographic anatomy for the palpatory diagnosis, and 
the histology for the microscopic diagnosis. 

Topographic Anatomy of the Female Genital Organs. Normal 

Palpatory Findings. 

The external genitalia (vulva) consist of the labia majora and 
minora, the clitoris and vestibule, and are separated from the vagina 
by the hymen. 

The labia majora (labia pudenda majora) are two thick folds 
of skin, smooth on their internal surface and covered on the outer with 
epidermis; they unite in front by the anterior commissure and merge 
with the skin of the mons Veneris, which contains a thick 
pad of fat. Posteriorly the frenulum, a thin fold of skin, is 
stretched between the two labia, and behind the frenulum is the begin- 
ning of the perineum, which extends to the anus; while beyond it is the 
posterior perineum (Hinterdamm), reaching as far as the sacrum. In 
nulliparous women the labia majora approach each other so closely 
as to expose only the anterior margins of the labia minora; while in 
multiparse, owing to the lacerations of the posterior commissure and 
relaxation of the vaginal walls, the greater labia are widely separated, 
leaving the entrance to the vagina freely exposed. The mons Veneris, 
the outer surfaces of the labia majora, and the perineum as far as the 
anus and beyond, are covered with pubic hair in persons who have 
attained their sexual maturity. The upper boundary of the pubic hair 
represents a sharply defined horizontal line; while posteriorly it is 
gradually lost in the folds of the anus (crena ani). 

The labia minora are two thin folds of mucous membrane of 
varying length; in some cases only the anterior margin, in others a 
large portion of the structures projects between the greater labia. The 
labia minora merge with the inner surfaces of the labia majora at about 
their middle. Drawing the labia majora apart brings into view the 
clitoris, almost completely covered by the prepuce, a flaccid, movable 
fold of skin covering all but the tip of the clitoris. The frenulum takes 
7fi 



SPECIAL DIAGNOSIS 



77 



its origin at the lower surface of the cUtoris and divides into two portions, 
which diverge in a downward direction and merge witli the labia minora. 
Above, the prepuce comes in relation with the labium minus on each side* 
so that the upper extremity of the latter on each side arises from one- 
half of the frenulum and prepuce, which embrace the clitoris between them. 
By separating the labia m.inora the vestibule (vestibulum vagina) 
is brought into view. This is formed by the inner wall of the lesser, 
and adjoining portion of the greater labia, and in front by the clitoris 
and the divided frenulum. Posteriorly the vestibule is sharply divided 
from the perineum by the transverse frenulum. That part of the vesti- 




FiG. 35. — Introitds in a Nulliparous Woman After the First Coitus. (Original.) 



bule which forms a depression behind the frenulum is known as the 
fossa navicular is. The vestibule in front contains the opening of 
the urethra, immediately in front of the entrance to the vagina; on 
each side of the urethral orifice are two small, shallow depressions, and 
below the external orifice of the urethra a few small, barely visible ducts 
in the mucous membrane, which are occasionally permeable for a short 
distance to a thin sound (Skene's ducts). On the lateral wall of the 
vestibule, about 1 to 1.5 cm. in front of the posterior median line, out- 
ward alongside the hymen on each side, is found a very small opening, 
the duct of Bartholin's gland, which sometimes admits a very 
small sound. 

The vestibule is separated from the vagina by the hymen, an 
almost circular fold of mucous membrane, which begins at the external 
orifice of the urethra as a narrow ridge and gradually becomes higher 



78 



GYNECOLOGICAL DIAGNOSIS 



as it passes backward. The h3aneneal opening in a virgin is thus situ- 
ated eccentrically in front, and its size depends on the height (width) 
of the hymen. At the first coitus the hymen is ruptured (sometimes the 
membrane is only stretched), usually bilaterally down to the base, 
forming three flaps or folds, a larger median, and two smaller lateral 
segments (Fig. 35). In multiparae the remains of these segments are 
seen in the form of a few papillary elevations (carunculae myrti- 
formes) (Fig. 36). If the hymen is intact, the interior of the vagina 
cannot be seen; but when the hymen is ruptured, the lower segment of 
the anterior vaginal wall, and rarely the posterior, is exposed; in a 
multipara the vaginal mucous membrane at the introitus is arranged 







'4': 



Fig. 30. — Introitus of a Multipara. (Original.) 

in small folds. As the result of old perineal lacerations the introitus 
becomes still more enlarged. The lacerations destroy the anterior 
portion of the perineum and the frenulum, obliterating the fossa navic- 
ularis, and extend to the left or right from the median line into the 
posterior vaginal wall, so that the columna rugarum posterior is 
drawn over to the other side by its own elasticity. If the lacerations 
involve both sides of the vagina, the posterior wall (columna rugarum 
posterior) is prolapsed and hangs down like a tassel. 

This completes the inspection. The examination of the vagina 
requires the introduction of the finger, while the vaginal wall is studied 
with a speculum. 

The vagina, when the bladder and rectum are empty, runs from before 
backward, approximately parallel with and slightly below the antero- 



SPECIAL DIAGNOSIS 7^ 

posterior diameter of the pelvic outlet; it forms a muscular tube about 
8 cm. in length and is exceedingly variable in width. The anterior wall 
is in contact with the posterior, while the lateral walls 
form short connections between the two, so that the 
cross-section is represented by the following figure ^i^ . In the 
lower half of the anterior wall, immediately below the symphysis, is 
seen the prominence formed by the urinary meatus; about the middle 
of the anterior wall the prominence diminishes and gradually disappears 
altogether ( c o 1 u m n a r u g a r u m anterior). The posterior wall also 
contains in its lower half a somewhat smaller median prominence 
(column a rug arum posterior). From these two prominences 
transverse folds and wrinkles are given off on each side; these are most 
distinct in a nullipara, but rarely absent altogether even in women who 
have borne children, while the upper half of the wall is smooth. Above, 
the vagina is closed by the dome-shaped vaginal vault. The anterior 
wall is in intimate relation below with the urethra and above with the 
bladder. The posterior wall is firmly attached below to the perineal 
tissue, while the median third is loosely connected with the rectum, 
and the upper third also loosely conjoined with the peritoneum of 
Douglas' space. The lateral walls of the vagina are surrounded by the 
pelvic connective tissue. The vaginal walls, when moderately firm, 
are quite tense and firmly attached to the subjacent tissue. The state 
of the adjoining organs, whether full or empty, greatly influences the 
position of the vagina; when the bladder is full, the anterior vaginal 
wall, and when the rectum is distended, the posterior wall, protrudes 
into the lumen of the vagina. Above, in the vaginal vault, lies the 
vaginal portion of the cervix. 

The superficial layer of the squamous epithelium which covers 
the vaginal wall is in a more or less constant state of desquamation, so 
that the walls of the vagina are constantly covered with whitish masses 
of epithelium. The color of the mucous membrane varies with the 
degree of vascularity. Under ordinary circumstances the color is pale 
red, and the membrane glistens. 

The portio vaginalis is that portion of the cervix which projects 
into the vagina; it is situated behind the pelvic axis*; about 1^ to 
2 finger-breadths in front of the tip of the sacrum, at the level of a 
line between the two spines of the ischium; as a rule it occupies the 
median line, but lateral deviations not infrequently occur when the 



* The pelvic axis (curve of Carus) is a line running through the middle of the pelvic 
canal parallel with the anterior surface of the sacrum (Fig. 37). — The words "right" and 
"left" always refer to the right and left side of the patient. The terms "in front" and 
"behind" refer to a patient in the standing position; hence the anterior surface in the erect 
position corresponds to the upper surface in the recumbent position. 



80 



GYNECOLOGICAL DIAGNOSIS 



Portio 
Vaginalis 



body of the uterus lies obliquely in the pelvis. At the apex of the 
vaginal portion is the external os, which in a nulliparous woman forms 
a narrow transverse cleft in the anteroposterior direction 
(Fig. 38). After the first delivery slight lacerations remain, 
which increase the width of the external os (Fig. 39), sometimes so 
much so that the tip of the finger can be inserted into the lower portion 
of the cervical canal; thus the vaginal portion is divided into two lips. 
The cervix is surrounded by the vaginal vault in such a manner that the 
posterior lip is about twice as long as the anterior, and the supravaginal 
portion of the cervix is accordingly longer in front than behind. This 
makes the anterior vault appear flattened, while the posterior seems 

higher and more dome-like. The mucous 
membrane of the vaginal portion has a 
purplish-red color and is tightly stretched 
over the cervical tissue without forming 
wrinkles. The mucous membrane, which 
is exposed when the external os gapes, 
has an intensely red color and exhibits 
the oblique folds of the so-called arbor 
vittp. The boundary between the mucous 
membrane of the vaginal portion and the 
cervix in a nulliparous woman is exactly 
at the external os; in multiparse this 
boundary is displaced in every direction, 
so that the mucous membrane of the 
vaginal portion sometimes extends into 
the lower portion of the cervical canal, 
while, on the other hand, the red cervical 
mucous membrane may appear on the outer surface of the vaginal 
portion. These slight deviations from the normal are not to be 
regarded as pathologic. 

The healthy cervical mucous membrane constantly secretes a 
small quantity of glairy mucus, which becomes intimately mixed with 
the squamous epithelium desquamated in the vagina and forms the 
normal secretion of the genital apparatus. 




Fig. 37. — Sagittal Section through 
THE Pelvis with Pelvic Axis (curve of 
Carus). Vi. (Original.) 



The uterus is approximately pear-shaped and slightly flattened 
from before backward. Below the middle of the organ, in the region 
of the internal os, there is a slight constriction, and from that point 
down to the cervix the circumference of the uterus dimin- 
ishes. The part above the constriction is the body of the 
uterus (corpus uteri) ; the portion of the body situated between the 
openings of the Fallopian tubes is known as the fundus uteri. The size 



Uterus. 



SPECIAL DIAGNOSIS 81 

of the uterus varies considerably witliin normal limits. It is greatest 
in multiparous women during sexual maturity; considerably smaller 
in all dimensions in nulliparous women; and still smaller in old women. 
The measurements in a sexually mature woman are: distance between 
the two tubes about 5 cm.; thickness of the body about 3 cm.; distance 
from the fundus to the external os about 9 cm. The length of the cavity 
in a sexually mature uterus is 7 cm.; in nullipara;, often somewhat less; 
in old women, 5 cm. The normal uterus is hard and unyielding and 
cannot be indented with the finger; in the region of the internal os, 
however, it has a certain softness and flexibility. When the bladder is 
empty, the body of the uterus lies on the upper wall of the bladder, 
while the fundus reaches almost to the posterior wall of the symphysis, 
the highest point of the body being below the plane of the pelvic inlet 
(Fig. 40). The body is usually situ- 
ated exactly in the middle line. 





Fig. 38. — Vaginal Portion of a Fig. 39. — Vaginal Portion of a 

Nullipara. (Original.) Multipara. (Original.) 

although slight deviations to one side or the other are quite common. 
In such a case the corpus is displaced to one side and the vaginal 
portion to the other. The body forms with the cervix an obtuse 
angle, which is usually about 135°, but is subject to individual varia- 
tions which have no significance. The normal uterus is movable 
within wide limits. When the bladder is full, the body is first elevated 
and then the entire uterus is forced against the posterior pelvic wall, 
and at the same time a little to one side and upward. When the rectum 
is full, the cervix is displaced downward and to the other side, i.e., 
usually to the right. AYhen the ampulla of the rectum is greatly dis- 
tended with fecal matter, the entire uterus is displaced upward and to 
the other side. These abnormal positions disappear and are replaced 
by the above described normal conditions when the bladder and rectum 
are evacuated. 

The body of the uterus is covered with peritoneum except along 
the lateral aspects. In front, at the level of the internal os, the peri- 
toneum passes from the upper wall of the bladder to the uterus, forming 



82 GYNECOLOGICAL DL4GNOSIS 

the anterioi" reflection or fold, and covers the anterior surface of 
the body, the entire fundus, and the entire osterior walL Here it is 



A. hypogastrica 
Promontorium / V. hypogastrica 

Ureter , /' / Infundibulum tubse uterince 



/ 



Ligamentum suspensorium ovarii 
V. iliaca externa 

Ovarium (facies medialis) 

Ampulla tubse uterina? 
Ligamentum ovarii proprium 

Fundus uteri 
Ligamentum teres uteri 
Plica vesicalis transversa \ 

Vertex vesicae \ 
\ 
Ligamentum \ ^ 

umbilicale laterale 






\ Peritoneum parietale 

\l n 
\ Corpus uteri 

/ \ (facies inte.stinalis) 

\ / Ofificium internum 

/ uteri 

/ / Plica rectouterina 

> / [Douglasi] 

M. rectouterinus 

Fornix 



Excavatio 
rectouterina 
/'[cavum 
/ Douglasi] 




Lig. umbilicale 
medium 
Symphysis ossium 

pubis ^ 

I.abium majus pudendum 
Corpus uteri (facies vesicalis) ' 

Labium minus pudendum ' 



TV rT 

Orificium urethras externum ' / / / 
■ /^/ 

I / ■! 

/ / / 

Orificium urethra? internum / / 



Urethra ' 



/ 




\ Os coccygis 

\ 

»- \ M rectococcvgeus 
\ \ 

\ Intestinum rectum 
\ Labium posterius 

Orificium externum uteri 
Labium anterius 



Anus 



Orificium vaginae / / 

Hymen [femininus] / 

Fossa navieularis [vestibuli vaginae 

Fig. 40. — Median Section of the Female Pelvic Organs. (From Spalteholz's Atlas, p. 601.) 



I Vagina 

Excavatio vesicouterina 



depressed more than in front, covers the upper third of the posterior 
wall of the vagina, and forms the posterior reflection or fold, passing to 
the posterior pelvic wall of the rectum and merging with the peritoneum 



SPECIAL DIAGNOSIS 



83 



of the posterior abdominal wall. In this way there is formed in front, 

between the bladder and uterus, the v e s i c o - u t e r i n e pouch; behind, 

between the uterus and the posterior pelvic wall or rectum, 

is the recto-uterine pouch or Douglas's space, 

the lowest point of which is situated about at the junction of 



Peritoneum. 




Fig. 41. — Showing the Uterds with its Covering of Peritoneum and Ligaments; Anterior 
View. (From a preparation in the Berliner Kgl. Universitats-Frauenklinik.) (Original.) The dotted -lias 
indicates the boundary between the firm and loose attachments of the peritoneum. V^. 

the middle and upper thirds of the vagina. The vesico-uterine exca- 
vation represents a mere cleft when the uterus lies on the bladder. 
The lowest portion of Douglas's space is also cleft-shaped; while 
above, the space is mostly filled with coils of intestine. The peri- 





Fig. 42. — The Same; Posterior View. (Original.) The dotted line represents tlie boundary between 
the firm and loose attachments of the peritoneum. }4. 

toneum is inseparably united to the fundus and adjoining portions 
of the body, while its connection with the lower portion of the body is 
quite loose, owing to the connective tissue intervening between it and 
the uterus. In front the boundary between the closely adherent and 
loosely attached peritoneum forms a flattened curve with the convexity 
directed downward; posteriorly it forms a spur which extends down to 
the posterior surface of the cervix (Figs. 41, 42). It follows from this 



84 



GYNECOLOGICAL DL\GNOSIS 



relation of the peritoneum to the uterus that extraperitoneal neoplasms, 
exudates, or hematomata may separate the peritoneum from the uterus 
and form extensive adhesions with the uterine wall. 

The lateral aspects of the uterus are not covered with peritoneum. 
Here the two layers which cover the anterior and posterior walls of the 



Epooplioron (ductuli traiisyersi) 
Ductus epoopliori longitudinalis [Gaei'taeriJ 
Mesosalpinx 

Plica istlimica I ■ 



Isthmus tuboe uterinae 
Pars uterina tub; 
Ostium uterinum tuba; 



Plica? ampuUares 

Ampulla tubae uterinse 
dibulum 
uterinae 

rise tuboe 



Cavum uteri___ 
Tunica muco^a_— ,- 
Tunica muscularis__, 

Margo lateralis, 

Tunica serosa.. 

Plicse palmatfp,.,-it'— 1— '"i 



Labium posterius (_ 

Orificium 
externum uteri 

Labium anterius. 





Ligamentum ovarii 
., proprium 

• f Orificium internum 

uteri 
Canalis cervicis uteri 

Portio supravaginalis 

[cervicis] 



Fmibiia o%arica 

Appendix veMculosa [Morgagnii] 

'^ \ lolliculus oophorus vesiculosus[Graafi] 

' \ Corpus luteum 

^ Hilus ovarii 

Ovarium dextrum 



Portio vaginalis 
[cervicis] 



Paries anterior 

vaginae 
Tunica mucosa 



organ leave the uterus and 
form the broad liga- 
ment, which accordingly 
represents a reflection of 
the peritoneum. The two 
layers of the broad liga- 
ment are unequal in length, 
corresponding to the two 
reflections of the perito- 
neum, which are separated 
at the different levels. The 
anterior layer extends only 
to about the level of the 
internal os; from that point 
it is reflected forward, 
passes to the anterior pelvic 
wall, and merges with the peritoneum of the anterior abdominal wall. 
The posterior layer descends much more deeply into the pelvis, joins the 
lateral lining of the recto-uterine excavation, and as such descends to 
the apex of Douglas's space. The upper portion of the broad ligament 
terminates laterally in a free border, which extends from the infundib- 
ulum tubcT, passing by the ovary, to the pelvic wall, and merges with 
the parietal layer of the peritoneum on the ileo-psoas muscle; this is 



Tunica muscularis 



Rugae vaginales 

Columna rugarum 
anterior 



Fig. 43.- 



-Vagina, Uterus, Right Fallopian Tube and Ovary. 
(From Spalteholz's Atlas, p. 598.) 



SPECIAL DIAGNOSIS 85 

known as the inf undibulo-pel vie ligament (Figs. 41-42). In the 
erect posture the median portion of the broad hgament corresponds to 
the anteverted position of the uterus and occupies the horizontal plane. 
In the lateral portion of the broad ligament, between the abdominal 
extremity of the tube and the ovary, is the epoophoron, a collection 
of small canaliculi the longest of which is usually convex, with the con- 
vexity presenting upwards and running from the infundibulo-pelvic 
ligament to the ovary; while the remaining canaliculi, about 8 to 10 
in number, pass from the inner surface of the ligament parallel to the 
outermost portion of the ovary (Fig. 43). The canaliculi are the remains 
of the Wolffian duct and the tubules of the primitive kidney. To the me- 
dian side is the small paroophoron, a small aggregation of cana- 
liculi also derived from these embryonal structures. 

The round figments are two muscular cords about the thick- 
ness of a pencil, which arise from each side of the fundus immediately 
in front of the tube, pass in a curved line between the two layers of 
the broad ligament, and extend first to the lateral and Round 

then to the anterior abdominal wall (Fig. 41). From this Ligaments. 

point they pass downward and enter the internal ring and, traversing 
the inguinal canal, emerge from the external ring and are lost in the 
subcutaneous cellular tissue of the labia majora. 

The sacro-uterine (recto-uterine) ligaments, or folds of 
Douglas, are two flat peritoneal folds which separate from the pos- 
terior layer of the broad ligament at the point where it merges with the 
lateral wall of Douglas's space. They extend from the Folds of 

region of the internal os to the anterior sacral wall, where Douglas. 

they are lost at the level of the second or tliird sacral vertebra. Behind 
the cervix they frequently unite to form a loop (Fig. 46). The folds 
of Douglas contain firm connective tissue and smooth muscle fibres 
(M. retractor uteri, Luschka). 

Palpation of the Uterus. After the finger has been introduced 
into the vagina it is rotated so that the volar surface is directed upward 
and passed into the anterior vaginal vault, or — a still better procedure 
for fixing an easily movable uterus — the index finger is paipation 

introduced into the anterior vaginal vault and the middle "^ ''"^ uterus, 
finger placed against the vaginal portion of the cervix or into the pos- 
terior vaginal vault. The external hand, with the fingers slightly flexed, 
is placed on the abdomen, about three finger-breadths above the 
symphysis, with the finger tips directed toward the umbiHcus. This 
brings the uterus between the internal and the external hand (Fig. 3). 
Without moving the internal fingers the abdominal wall is slowly de- 
pressed with the external hand, and if the uterus is in its normal position 
it will then be felt between the fingers; if not, the fingers of the two 



86 



GYNECOLOGICAL DIAGNOSIS 



hands will come together. The beginner at first merely receives the 
impression of a firm resistance at the site of the uterus; but if he will 



. Mesovarium 
Ligamentum suspensorium ovarii / 

Ampulla tubae uterinae 



Infundibulura tubae uterinae 
Facies lateralis ovarii 
/ /Margo liber ovarii 



Ureter 

^Arteria et vena uvaricae • \ 

Ligamentum latum uteri 

Facies intestinalis uteri 
Ligamentum teres uteri 
Fundus uteri 
Peritoneum parietale 



estinum rectum 
exura sacralis) 

xcavatio recto- 

uterina [cavum 

Douglasi] 



Tunica serosa vesicae 



Vertex vesicae 




Ramus superior 
ossis pubis / 

Corpus clitoridis 

Praeputium clitoridi 

Frenulum clitoridis 
Labium majus pudendum 



Vsstibulum vaginae ! 

Labium minus pudendum 



^'agiIla 



A . uterma iq 
parametrio 

, Mesometriuin 

' Tntestinum rectum Cflexura periuealis) 
M. levator ani 
CoUum vesica' 

Ramus inferior ossis ischii 
M. bulbocavernosus 



Fig. 44. — Female Pelvic Organs. (From SpaltehoU's Atlas, p. 000.) 

keep his fingers on the uterus for a while, and palpate in various direc- 
tions, — in front, to each side, and toward the vaginal portion — he will 



SPECIAL DIAGNOSIS 87 

recognize the organ by its shape and its connection with the vaginal 
portion of the cervix. The shape, the surface, and the size of the uterus 
should be noted; also the consistency, which is to be regarded as normal 
if the uterus is so hard and unresisting that it cannot be indented with 
the finger; next, the position of the uterus is determined, and finally 
its mobility. The uterus, which is surrounded by normal connective 
tissue and peritoneum, is movable in all directions, i.e., it can be 
drawn towards the symphysis, pushed into the hollow of the sacrum, 
displaced towards the lateral pelvic wall, elevated along with the 
fundus to a point about half way between the umbilicus and the 
symphysis, and displaced so far downward that the vaginal portion of 
the cervix almost reaches the introitus. These movements, which 
can be performed without causing any marked pain, incidentally 
serve to test the elasticity of the ligaments. The two broad ligaments 
by means of their elasticity maintain the uterus in 
the median line; the round ligaments keep the fun- 
dus forward; and the function of the sacro-uterine 
ligaments is to prevent the cervix from dropping 
forward and downward. 

Palpation of the Ligaments. Only the 
round ligaments and the sacro-uterine ligaments, 
which are reinforced with muscular tissue, are acces- 
sible to palpation. The broad ligaments, unless 
they are thickened from pathologic deposits, cannot and bhoad L^AM^Em^ 
be felt. As a rule, however, the round ligaments ^°"sinai.) 
are not felt because they are not sufficiently stretched and because the 
intermediate segment is completely embedded in the broad ligament. 
On the other hand, if the uterus is enlarged (myoma) and elevated 
above the pelvic inlet, the round ligaments can be palpated p^i ation of 
at the point where they are inserted into the uterus by t^e Ligaments, 
passing the external hand along the lateral aspect of the uterus in a 
direction perpendicular to the course of the ligaments. In the same 
manner the part situated near the horizontal ramus of the pubis can be 
felt by making firm pressure with the external hand and passing it 
up and down in a direction perpendicular to its course. The recto- 
uterine ligaments can only be palpated with any degree of cer- 
tainty through the rectum. One finger is introduced through the fold 
of Kohlrausch and, by lateral and anterior movements, the ligament 
which is usually curved, can readily be felt, especially if it is placed on 
the stretch by forcing the uterus forward. If the ligaments cannot be 
reached with one finger, the uterus is brought nearer by drawing the 
cervix down with a double tenaculum; or two fingers are introduced 
into the rectum under anesthesia. 




88 GYNECOLOGICAL DIAGNOSIS 

The' ovaries are almond-shaped organs about 4 cm. long, 2 to 
2.5 cm. broad, and 1 to 1.5 cm. thick. Their size is subject to certain 
variations, due to maturation of the follicles and the formation of 
corpora lutea. The ovaries are situated near the lateral 
wall of the true pelvis, immediately beneath the linea 
arcuata. The upper pole does not reach quite to the iliac vessels, while 
the lower just fails to touch the floor of the pelvis. They are freely 
suspended in such a way that the largest diameter is parallel to the long 
axis of the body; the hilus is directed forward, the free convex border 
backward, and the lateral surface almost comes in contact with the 
pelvic wall. The ovary is attached in two directions: the inferior, 
uterine pole gives off a firm, round fibrous band, the ovarian liga- 
ment, which is from 2 to 3 cm. in length, situated between the two 
layers of the broad ligament, and inserted in the lateral aspect of the 
uterus immediately below the tube (Fig, 42). Above, the infundibulo- 
pelvic ligament passes over the upper pole to the pelvic wall ; the lateral 
portion of the infundibulo-pelvic ligament, which suspends the ovary 
to the pelvic wall, is also called the suspensory ligament of the 
ovary (Figs. 44 and 46). The ovary is not covered with peritoneum, 
being attached to the posterior layer of the broad ligament by a reflec- 
tion of the peritoneum, about 3 to 5 mm. wide, known as the mes- 
ovarium (Figs. 42 and 45), so that only the portions of the ovary 
immediately adjacent to the hilus are covered with peritoneum. If 
the uterus is placed very obliquely, the ovary is found on the side toward 
which it is displaced, a little farther back; while the other ovary is 
drawn more toward the middle of the pelvis. 

The ovaries fnay be most easily palpated through the vagina. 
In order to find the left ovary, the left vaginal vault is forced toward 
the linea arcuata with the internal fingers, which are bent outward and 
Palpation of upward, and the external hand — with slightly flexed fingers 
the Ovaries. — -g pj^cgj qu thc abclomeu a little to the inner side of the 
internal hand ; both hands are then brought together. In this way the 
ovary is usually found at the first attempt. It is recognized as an oval 
body of the size mentioned, and of firm, but not hard consistency. 
The ovary is very movable and easily slips from between the fingers — 
a point of great importance in diagnosis. As a rule, the ovary is very 
sensitive to moderate pressure. 

If the ovary is not found at the place indicated, the correspond- 
ing half of the pelvis must be carefully searched by passing the fingers 
in close contact, as described, up and down from behind forward. 
The fingers must be kept constantly in contact, otherwise the ovary 
will slip through without being noticed. It is not difficult for a prac- 
tised examiner to find the ovary by starting at the cornu of the 



SPECIAL DIAGNOSIS 



89 



uterus and following the tube or ovarian ligament, as either of these 
must eventually guide him to the ovary. The right ovary is also pal- 
pated with the left hand. The wrist is strongly depressed, the finger 
tips of the internal hand are raised, and the hand at the same time is 
slightly rotated outward; the search is made chiefly with the finger 
tips. Although the position of the hand is somewhat more inconvenient 



Intestinum rectum 
Ureter 



Arteria 
et Venn 
ovarica' 



Jlesocolon sigmoideum 
1 



Orificium excavationis reet.outerina> 
, [cavum Douglasi] 

Plica rectouterina [Douglasi] 



Peritoneum parietale 



/ /suspensonum ovarii 



Ovarium 

(facies medialis) 



/ >w' / / / tubee uterinae 




Istlimus tubae 
uterinae 



Fundus uteri 



Vesica urinaria Plica vesicalis transversa uteri 



Fig. 46. — Female Pelvic Organs. (From Spalteholz's Atlas, p. 602.) 

than in palpating the left ovary, it can nevertheless be found without 
any difficulty, especially if the examiner sits or stands on the left side 
of the patient. The other hand need be employed only if it is found 
impossible to make an examination of the right adnexa in this way. 
In examining the ovaries the points to be noted are: the size, shape, 
surface, degree of sensitiveness, and mobility. The chief sources of 
error are scybala, or, on the left side, the empty sigmoid flexure, which 
are frequently mistaken for the ovaries. 



90 



GYNECOLOGICAL DL\GNOSIS 



Fallopian 
Tubes. 



The Fallopian tubes are small hollow muscular cords from 10 to 12 
cm. in length. They are situated in the upper free margin of the broad 
ligament and are therefore covered with peritoneum, so that only a 
small portion of their lower periphery is directed toward 
the connective tissue of the broad ligament (Fig. 48). 
From the open, fimbriated extremity the fimbria ovarica passes 
along the infundibulo-pelvic ligament to the ovary. The Fallopian 
tube begiris at the cornu of the uterus, runs at first horizontally immedi- 
ately behind the anterior pelvic wall, takes an upward direction just 
before reaching the ovary, passing over that structure, and dips down 
with its abdominal extremity into the lateral portion of Douglas's space, 

where the infundibulum occu- 
pies a position near the sacro- 
iliac articulation. The tube is 
accompanied by the adjoining 
portion of the broad ligament, the 
so-called mesosalpinx, which 
also passes over the ovary and 
covers the hilus almost completely 
^Fig. 46). 

The tubes can be palpated 
only when the abdominal walls 
are unusually yielding. The uter- 
ine extremity is a little thicker 
and is more readil}^ palpated than 
the abdominal end, which is too 
soft to be felt. The tubes are 
found by holding the fingers close 
together and passing them to and 
fro in a direction perpendicular to the line of the tubes, when they 
may be felt as soft cords about the thickness of a knitting-needle. 
Palpation of The clilcf source of error is the ovarian ligament which, 
the Tubes. howcvcr, IS sliorter and firmer in consistency. Normal 

tubes are not painful. 

The parametrium, or pelvic connective tissue, is part of the con- 
nective tissue that is found all through the body, with which it is 
continuous. The main stem of the connective tissue forms a horizontal 
layer, which is bounded below by the levator ani, and 
covered above with peritoneum (Fig. 49). As the latter 
dips down it forms a number of pockets of varying depth. The upper 
boundary of the pelvic peritoneum is very irregular, and its thickness 
varies greatly in different places. The parametrium is best developed 
between the cervix and the pelvic wall, where it is known as the basis 




Fig. 47. — Horizontal Section of the Pelvis 

THROUGH the MiDDLE OF THE Sy.MPHYSIS .\ND THE 

Third S.\cral Vertebra, Showing the Horizontal 
Extension of the Pelvic Connective Tissue (modi- 
fied after Freund): In front, the bladder; in tlie middle, 
the cervix; behind, Douglas's space and the rectum; 
on each side of the cervix, the ureters. J3. 



Parametrium. 



SPECIAL DIAGNOSIS 



91 



of the broad ligament or cardinal ligament. It supports 
most of the vessels and the ureter. This main portion of the pelvic connec- 
tive tissue is perforated in front by the bladder and urethra, in the middle 
by the genital canal, and posteriorly bj^ the rectum, so that these struc- 
tures are enveloped in connective tissue (paracystium, paracolpium, 
paraproctium). Owing to this arrangement, the connective tissue is least 
abundant in the median line, while in the interval be^tween the lateral 
surface of the organs and the pelvic wall are found the two chief masses 
of connective tissue, which are connected in the middle, particularly 
in front of and behind the cervix, by bands surrounding the latter 
(Figs. 47 and 49). This main central portion of the parametrium sends 
out processes in various directions. 
Above it gives rise to the connec- 
tive tissue of the broad liga- 
ment, which gradually becomes 
narrower and extends to the tube 
(Fig. 48) ; in front it comes in 
direct relation with the cavum 
praeperitoneale Retzii, sur- 
rounds the lateral wall of the 
bladder, and passes upward to 
the abdominal wall as the retro- 
peritoneal tissue. The retro-cer- 
vical connective tissue gives off 
a branch known as the recto- 
vaginal septum, which dips 
down between the posterior wall 
of the vagina and the rectum 
and, becoming gradually thinner, 
extends to a point half way up the posterior vaginal wall. The large 
masses of connective tissue along the pelvic wall are in direct commu- 
nication with the connective tissue lying on the iliac bone ; posteriorly 
the peritoneum merges with the retroperitoneal connective tissue and, 
through the sciatic notch, with the connective tissue underneath the 
gluteal muscles. In front it escapes from the pelvis underneath Poupart's 
ligament and passes to the connective tissue of the thigh. 

The connective tissue is everyw^here so soft that it offers no 
resistance to palpation. Wherever there is normal connective tissue 
the palpating fingers come together without feeling anything. 

The urinary bladder is interpolated between the vagina and 
uterus (Figs. 40 and 44). The lower wall of the bladder is intimately 
connected with the anterior wall of the vagina and adjoining para- 
metrium. The posterior wall of the vagina is connected with the 




Fig. 48. — Sagittal Section through the Pelvis 
TO THE Left of the Uterus, Showing the Broad 
Ligament Rising out of the Horizontal Layer 
of Connective Tissue (modified after Freund). In 
front, the bladder; behind it, the ureter; behind that, 
the vaginal portion within the vault of the vagina, 
which is seen in oblique section, ji. 



92 



GYNECOLOGICAL DIAGNOSIS 



anterior wall of the cervix from the internal os downward to the 
insertion of the vaginal vault; when the bladder is distended with 
Urinary luine, the loosely adherent peritoneum is separated from the 

Bladder. auterior wall of the uterus, and larger portions of bladder and 

uterine wall are in contact. Laterally from the cervix the bladder is also 
connected with the parametrium. The upper wall is covered with peri- 
toneum and the anterior is attached by means of loose connective tissue 
to the posterior wall of the symphysis and the horizontal ramus of the 
pubes. When the bladder is empty, the upper wall is hollowed out like 
a saucer and in contact with the lower wall. As the organ fills, the urine 




Fig. 49. — Frontal Section Through the Female Pelvis. (Modified after Waldeyer.) The vagina 
has been opened, sliowing the vaginal portion of the cervix; above, the antefiexed uterus with its peri- 
toneal coverings; on each side, the base of the broad ligament traversed by the ureter; the vessels are dissected 
out on the left side, while on the right they are still covered with peritoneum. 



collects first in the lateral portions of the bladder, then the upper wall 
separates from the lower, until finally, if the distention continues, the 
shape of the bladder becomes approximately spherical. 

When empty the bladder is felt to be soft and flabby; even when it 
contains a moderate quantity of urine it is still so flabby that it cannot 
be palpated. There must be from 300 to 400 c.c. in the organ before 
Palpation of it h^s tlic rcsistaiice of a moderately cystic tumor, which 
Bladder. jg oftcu sltuatcd a little to one side of the median line. A 

greatly distended bladder may simulate a cystic tumor, and when it 
is filled to bursting it may even give the impression of a solid tumor. 

The cyst OS CO pic findings in the normal bladder are as 
follows (Fig. 50): 



SPECIAL DIAGNOSIS 



93 



As the cystoscope is introduced into the bladder, the internal 
orifice of the urethra, which forms the boundary between the two 
structures, is distinctly seen. At the anterior boundary, where the 
transition takes place at a sharp angle, the orifice appears sharply out- 
lined as a bright (translucent) ridge of mucous membrane; behind, 
where the transition is gradual, the intensely red, velvety urethral 
mucous membrane gradually merges into the mucous membrane of 
the bladder; depending on the position of the cystoscope, the transi- 
tion at this point may also be more or less abrupt. After the prism of 
the cystoscope has entered the bladder, the wall of the viscus comes 
into view. The mucous membrane is yellowish-white, often intensely 
white in color, and the entire periphery of the bladder, as far as the pos- 
terior wall, is almost devoid of vessels; only occasionally a slender vein 
or artery appearing here and there. In 
the trigonum the injection is more abun- 
dant, and vessels are seen extending in 
fan-like formation from the urethral orifice 
toward the openings of the ureters and 
sometimes surrounding them; the entire 
mucous membrane, owing to the greater 
vascularity, shows a diffuse blush. 

The most important part of the picture 
is the trigonum, which is bounded by 




the two ureteral 
ureteric ligament 
pending on the 
iireteral openings 



Fig. 50. — Cystoscopic Picture 
OF THE Normal Bladder. (Modified 
after Zangemeister.) 



orifices and the inter- 
connecting them. De- 
distance between the 

and their distance from the urethral orifices, the 
angle of the trigonum is found to be either an acute or obtuse angle. 

The ureteral orifice is distinctly seen as a small opening, shaped 
like a cleft or occasionally round, and lying near the median line on a 
slight oval prominence, which gradually merges on each side with the 
wall of the bladder. The inter-ureteric ligament which connects the 
two eminences is often merely indicated and sometimes cannot be seen 
at all. By close observation the urine may be seen spurting out of 
the ureteral orifice and setting up a vortical movement in the injected 
fluid; the frequency of the phenomenon will depend on the secretory 
activity of the kidneys. The two ureters usually work synchronously; 
as the urine is extruded, the contraction of the ureter not infrequently 
can be seen, particularly if the eminence surrounding the orifice is well 
marked. 

Aside from the trigonum, the normal bladder-wall presents a 
uniform picture, except above, at the vertex, where one or two points 
of interest may be noted. At the highest point of the vertex is a small 



94 GYNECOLOGICAL DL\GNOSIS 

air-bubble, formed by the air which enters with the cystoscope; it 
varies in size and is in close contact with the upper wall of the bladder. 
This air-bubble is most useful for purposes of orientation. Occasionally 
one may see slight protrusions of the vesical wall, corresponding to 
neighboring organs in close contact with the viscus; as, for example, 
in front, the swelling of the symphysis, and above, the "shadow of the 
uterus" (^Stockel). Occasionally the peristaltic movements of the 
coils of intestine can be distinctly seen through the upper wall of the 
liladder, as well as a displacement of the organ synchronous with the 
respiratory movements. 

The ureter passes immediately behind the insertion of the infun- 
dibulo-pelvic ligament, over the ilio-psoas muscle, and enters the 
true pelvis, where it runs behind and below the ovary and enters the 
broad ligament (Figs. 44, 46, 49); traverses the connective 
tissue, and approaches the cervix from above to within 
about 1 cm. at the level of the internal os iFig. 47): from that point 
it passes in a direction from above, behind and outside — downward, 
inward and forward to the anterior vaginal vault, with which it remains 
in "close contact for a distance of 1 to 1.5 cm., and enters the posterior 
wall of the bladder from behind and above (Fig. 44). 

Only that short portion of the ureters which is in contact with the 
anterior vaginal vault is accessible to palpation. They may be felt 
for a distance of 1.5 to 2 cm. from about the point where the urethra 
Palpation of ^^ip^ dowu to enter the bladder, in the lateral portion of 
the Ureters. ^|-^^, autcrlor vagiual vault, toward the base of the broad 
ligament, and give the impression of smooth, easily movable cords 
which are lost as they pass upward. They form a triangle open posteri- 
orly. Vntler normal conditions palpation of the ureters is very uncer- 
tain; when the tissues are thickened, the ureters can be felt somewhat 
more easily and over a considerable extent. Palpation can be rendered 
much easier by introducing an ureteral catheter. 

The rectum enters the left side of the true pelvis in front of the 
sacro-iliac articulation and, approaching the median line, courses down- 
ward along the anterior excavation of the sacrum. At about the level 
of the linea arcuata the rectum loses its mesentery, and 
from that point, covered with parietal peritoneum, is 
extra-peritoneal down to the floor of Douglas' space; from this point 
down to the anus it is completely enveloped in pelvic connective tisstie 
(Figs. 40, 44 and 40). 

The rectum is situated approximately in the median line in front 
of the sacrum, and, when it ;s empty, can be felt as a movable band 
about as wide as a man's finger; when it contains feces, soft doughy 
masses Utay be felt in the lower portion of the canal. AVhen the 



SPECIAL DIAGNOSIS 



95 



finger is introduced into the rectum, it first enters the ampulla; 
when the gut is empty, the walls are in close contact, and farther 
up are often difficult to separate. About 6 cm. above the Palpation 

anus a crescentic fold of mucous membrane is felt, chiefly "^ ^^^ Rectum. 
in the anterior and right wall of the rectum and encroaching on the 
lumen (fold of Kohlrausch) (Fig. 40). 

On the left side, at the level of the pelvic inlet and a little above 
it, is felt the sigmoid flexure, which projects more or less into the 
pelvis, depending on the length of its mesentery, and occasionally may 
occupy the median line in front of the uterus. When empty it forms 
a ribbon-like, very movable band; when it is full, soft masses of feces 
or hard scybala are sometimes felt and may simulate the ovary or 
tumors of the adnexa (Fig. 51). 




Fig. 51. — Sigmoid Flexure Filled with Feces. P.-F. (palpatory findings). 'A. (Original.) 

For purposes of orientation it is important to be familiar with the 
bony parts of the pelvis that can be palpated through the vagina. 
We can feel the posterior wall of the symphysis and the horizontal and 
descending ramus of the pubes. Only the upper portions Bony Parts 

of the ascending ramus of the ischium are accessible to °^ ^^^ Peivis. 
palpation, while the tuberosity of the ischium and ascending portions 
can rarely be felt through the superimposed soft parts. With regard 
to the descending ramus of the ischium, the spine is readily felt and is 
an important landmark by which we determine the level of the vaginal 
portion of the cervix. The linea arcuata can be readily palpated if 
the vaginal walls are not too resistant, particularly under anesthesia; 
also the upper border of the sciatic notch. The promontory and the 
upper segments of the sacrum can be reached if the pelvis is not too 
wide; while the posterior, widely arching portions of the sacrum can 
rarely be felt from in front. 



96 GYNECOLOGICAL DL4GNOSIS 

Occasionally an individual muscle can be felt in the true pelvis, 

particularly if it is in contraction. The pyriformis forms a slight 
prominence on the anterior wall of the upper half of the sacrum. Along 
Muscles in the ^^e anterior pelvic wall on the obturator foramen the flat- 
True Pelvis. tcued obturator intcrnus can occasionally be felt, and 
at the level of the pelvic inlet one feels the belly of the iliopsoas 
muscle, extending from within and above — downward and outward. 
Lymphatics and Lymph=Qlands. The lymphatics of the entire vulva 
and lower third of the vagina emptj^ into the inguinal glands. 
The latter also receive a lymphatic vessel which originates at the cornu 
Lymphatics and of the utcrus and passes through the inguinal canal in 
Lymph-glands, eompauy with the round ligament. The lymphatics of 
the middle third of the vagina traverse the pelvis singly; those of the 
upper third, in company with the lymphatics from the vaginal portion 
of the cervix, unite to form large masses which pass through the base 
of the broad ligament (Fig. 52) to the hypogastric glands situated 
near the point where the uterine artery is given off, and to the two or 
three iliac glands which are found at the point where the hypogastric 
and iliac arteries separate. These iliac glands also receive a few large 
trunks from the lower portion of the body of the uterus. The lymphat- 
ics of the upper portion of the body and those of the fundus collect at 
the lateral border of the uterus to form larger trunks, anastomose with 
the lymphatics of the cervix, and pass along the upper border of the 
broad ligament in company with the lymphatics of the tube and ovaries 
to the infundibulo-pelvic ligament, in which they pass upward and 
then dip down on the anterior surface of the vertebral column to enter 
the lumbar glands, which surround the aorta at the level of the 
lower border of the kidney. A few smaller lymphatics from the upper 
part of the vagina and cervix enter the sacral glands which are 
situated in front of the sacral foramen. A few smaller Ij^mph-glands 
are lodged in the tissue of the parametrium. 

The pelvic glands can rarely be palpated unless they are 
enlarged, when they can be demonstrated under profound anesthesia 
Palpation of the by inserting two fingers into the rectum toward the linea 
Pelvic Glands. arcuata and making pressure with the external hand at 
the corresponding point. The lumbar glands can be palpated only 
when they are very much enlarged. 

Finally, it is necessary for a complete gynecologic diagnosis 

Blood -Vessels 

for the examiner to be familiar with the blood=vessels 
which supply the internal female sexual organs. They receive their 
blood from two directions: 

The internal spermatic or ovarian artery, which is given 
off directly from the abdominal aorta, crosses the iliac vessels near, 




Gland, tngitin. 



Fio. 52. — Lymphatic App'.hatos of the Femai.e Genitalia. (In part scliemane.) uit'ei l. 

and KronifT.) 






VBjm^e JseoV 



TSi^-AM 






lJ>Jn"^VI^^ dedV 



.ryu2 .0J>A1j -JM^^i;> 







MiD^or\^j\ b 






.nijj^j bnnsa 




Fig. o2.— Lymphatic Apparatds of the Female Genitalia. (In part schematic.) (After Doderleiu 

and Kronig:.) 



SPECIAL DIAGNOSIS 



97 



and in front of the ureter, enters the infundibulo-pelvic ligament 
opposite the pelvic inlet, follows the upper border of the ovary, which it 
supplies along with the tube, and anastomoses with the corresponding 
terminal branch of the uterine artery. 

The uterine artery, a branch of the hypogastric, is at first 
subperitoneal and follows the inner wall of the pelvis for a certain 
distance; it then leaves the pelvic wall and turns toward the median 
line, traversing the parametrium to reach the cervix, after giving off 



Ramus tubarius 
! 



Tuba uterina 
[Fallopii] I 



Ramus ovarii 
I 

Ovarium 




A. vesicalis inferior 



A. vesical is 
inferior, branch to vagina 

M. levator ani i 

Rectum 

Fig. 53. — Arteries of the Uterus and Surrounding Structures. (From Spalteholz's Atlas, p. 431.) 



near the vaginal vault the vaginal artery, which descends along the 
lateral wall of the vagina. The main branch of the uterine artery turns 
on itself at the cervix and follows a very tortuous course upward be- 
tween the two layers of the broad ligament along the lateral margin of 
the body of the uterus, supplying to both walls of the uterus branches 
which surround the body and anastomose with the arteries of the op- 
posite side. At the cornu it gives off one branch to the tube, another 
to the round ligament, and with its terminal branch supplies the ovary, 
running between the two layers of the broad ligament to meet the termi- 
nal branch of the spermatic artery. (Fig. 53.) 
7 



98 GYNECOLOGICAL DIAGNOSIS 

In a similar manner the veins carry off the blood of the internal 
genitalia in two directions. The veins of the ovary and of the lateral 
portion of the tube unite with broad anastomosing branches from the 
uterine vein, to form the spermatic vein, with the production of a 
dense plexus, the pampiniform plexus, which surrounds the sper- 
matic artery and dips down into the vena cava. The veins of the upper 
portion of the vagina and uterus join together at the lateral aspects of 
the organ to form the dense utero-vaginal plexus, and also unite 
to form the uterine veins, which traverse the parametrium, and 
empty into the hypogastric vein; the two plexuses anastomose 
freely with one another (Fig. 54). 

The arteries can be palpated when the vaginal 

Palpation of . . . 

the Blood- branches are dilated and pulsate distinctly. In the same 

way the pulsation of the large trunks along the pelvic wall 

can be felt through the rectum. The veins in the pelvic wall are 

perceptible to the sense of touch only when they are thrombosed. 

Histology. 

In the discussion of the normal histologic composition of 
the tissues we shall include only those parts of the sexual organs which 
are important from the standpoint of microscopic diagnosis. 
These are the vulva, urethra, vagina, vaginal portion, 
cervix, uterus and its mucous membranes, and Fallo- 
pian tubes. 

The vulva (labium majus, minus, clitoris, mons Veneris), like 

the skin of the female body, is everywhere covered with stratified 

squamous epithelium. Cylindrical in the deepest layers, the epithelium 

gradually becomes more cuboidal, while nearer the sur- 

Histologic ° •' . ' 1 T . 1 T 

Composition of face the elements are more circular and distinctly dentate 
(prickle cells) ; the superficial layer contains flat, horny cells. 
— The nuclei of the epithelial cells take the stain readily; they are often 
absent entirely in the horny layers. The stratified squamous epithelium 
everywhere contains papillae with blood-vessels and nerves. — The "exter- 
nal surface" of the labium majus is covered with well developed 
Labium ^air and sebaceous glands; the ducts of the latter open 

Majus. around the hair follicles, three or four being grouped around 

each hair. The orifice of the duct is situated somewhat underneath the 
epidermal layer. The sebaceous glands are of the acinous variety; 
they are lined with cuboidal and cylindrical epithelium, which is ar- 
ranged in several layers at the opening of the duct. The individual 
elements, which are forced upward and cast off by the growth of younger 
cells underneath, become enlarged and swollen by taking up fat drop- 
lets and gradually break down. In the duct the cuboidal and cylindri- 



SPECIAL DIAGNOSIS 



99 



cal epithelium of the acini is replaced by the stratified epithelium of 
the epidermis. — The sweat glands, which must be mentioned in 
addition to the sebaceous glands, are isolated and traverse the epidermal 
layer in corkscrew fashion. At their entrance into the subcutaneous 
connective tissue they are slightly dilated in the shape of a funnel and, 
after pursuing a straight or slightly spiral course through the sub- 
cutaneous tissue, they become convoluted in the deeper layers, at 



V. ovarica 



Ovarium 



Plexus uterovaginalis 
Rectum 



Ligamentum teres uteri 
\ 
Vesica urinaria 




v. haemor- 
/ rhoidalis 

superior 



V. dorsalis ._ 
clitoridis 



Plexus pudendalis 

V. pudenda interna 



Ureter 
Plexus 
haemorrhoidalis 
' externus 

M. levator ani 

Vv. uterinse 



Plexus vesioalis ' 

Plexus uterovaginalis 

Intestinum rectum 



A. uterma 

Vagina 



Vv. vesicales 
Fig. 54. — Veins of the Female Pelvic Organs. (From Spalteholz's Atlas, p. 464.) 

the level of the hair papillae, or sometimes immediately underneath the 
subcutaneous fatty tissue. The lining of the convoluted extremity of 
the canaliculi consists of cylindrical epithelium, while the shaft is lined 
with several layers (from two to three) of epithelial cells. — The loose 
connective tissue underneath the epidermis, which accommodates the 
hair follicles, sweat glands, blood and lymph vessels, and nerves, con- 
tains the fatty tissue arranged in lobules of varying size (Fig. 55). — 
The same constituents are constantly found both in childhood and in 
maturity. In childhood the imperfectly developed hairs (lanugo 



100 



GYNECOLOGICAL DL4GNOSIS 




Fig. 55. — Vulva of a New-born Child. The cutis contains 
sebaceous glands and sweat plands. The former are racemose, 
the latter tubular in structure: — Lanugo hair. (Original.) 



hair) appear as appendages of the relatively large sebaceous glands; 
while in sexually mature individuals the sebaceous glands seem to rep- 
resent appendages of the hairs (Fig. 56). — As the result of severe dis- 
ease (febrile conditions) 
marked changes in the 
size of the individual 
parts may occur. — In 
old age a general atro- 
phy of all the various 
parts takes place, the 
epidermis becomes atten- 
uated, the papillae disap- 
pear almost completely, 
and the boundary line 
between the papillae and 
the subcutaneous tissue, 
instead of being as before 
wavy, with a slight bulg- 
ing toward the deeper layers, becomes smooth and even slightly convex 
toward the surface. Both in the connective tissue and in the deepest 
layers of the epidermis 
pigmentation is seen 
in old individuals, while 
it is absent in the tissues 
of children. The lowest 
cylindrical epithelial cells 
of the epidermis (rete Mal- 
pighii) often appear brown 
or blackish in the micro- 
scopic picture and exhibit 
granular pigment. — 

For purposes of 
diagnosis it is impor- 
tant to be familiar 
with the various pic- 
tures, especially those 
which are oblique or hori- 
zontal sections, as well as 




Fig. 56. — Vulva of a Woman. The cutis contains sebaceous 
glands, sweat glands and hair. (Original . ) 



those produced by sections 
through the superficial and through the deep layers of the skin. One who 
has only had the opportunity to familiarize himself with the appearance 
of the epidermis in a vertical section will find orientation difficult in 
a flat section and will be in danger of mistaking sections of the epithelial 



SPECIAL DIAGNOSIS 



101 



plugs of the epidermis, which sometimes dip deep down into the tissue, 
for "solid carcinomatous plugs." — Transverse sections through a shaft 
of hair, sections of sebaceous glands and also of sweat glands may give 
rise to error if the examiner is inexperienced. 




Fig. 57. — a. Frontal Section of the Genitalia of a New-bokn Child. Clitoris, Hymen, Rectum. 
At the side of the hymen are Bartholin's glands "with their ducts. 6. Terminal Branch of Bartholin's 
Glands: High, translucent cylindrical epithelium with the nuclei situated near the base. (Original.) 

Bartholin's glands also deserve attention, as they must be ex- 
amined in disease and in malignant degeneration. The duct is situated 
in the lower third of the vulva, a little in front of the hymen; it is 
quite long, covered with stratified epithelium and often exhibits irreg- 



102 



GYNECOLOGICAL DIAGNOSIS 



Bartholin's 
Glands. 



ular dilatations. The lining epithelium of the duct contains numerous 
vacuoles; — preparations from new-born children contain, in addition to 
the main duct, one or two short accessory ducts which end 
blindly (Fig. 57). — The distal portion of the duct breaks up 
into several branches, so that Bartholin's gland appears to be made 
up of several lobules and exhibits a racemose structure. — The epithelium 
of the gland-duct in the region of the gland itself is of the high cylin- 
drical variety, with well-staining nucleus situated near the base. In 
the terminal branches the epithelium often is low. The epithelial 
cells are more translucent and, like the epithelium of the cervix, 
do not stain well (Fig. 58). — The clitoris is covered with stratified 

squamous epithelium and does not 
contain any glandular structures. 
The tissue contains well-developed 
vessels, especially those of the corpora 
cavernosa. — The inner aspects of the 
labia majora are devoid of hair; here 
we find only sebaceous and sweat 
glands, the latter disappearing at the 
junction with the labia minora. — 
The labia minora are covered 
with stratified squamous epithelium 
and contain chiefly sebaceous glands 
(epithelial derivatives) which are flat 
(umbrella or fan-shaped), and spread 
out underneath, and parallel with 
the squamous epithelium. In old 
age the glands undergo considerable atrophy. The beautiful, branch- 
ing, racemose gland lobules covered with epithelium are often replaced 
by hollow epithelial depressions which end abruptly, or may here and 
there be provided with a knob-like prominence at their extremities, 
the remains of the gland-body (senile condition). — In new-born chil- 
dren, and in most girls up to the age of ten or twelve years, the labia 
minora contain no sebaceous glands. Occasionally the beginning of 
sebaceous gland formation may be recognized as 
early as the sixth or seventh year; rarely at a still earlier 
date. The great paucity of sebaceous glands before the establish- 
ment of menstruation, compared to their abundance later on in the 
sexually mature woman, throws a special light on the development of 
these structures. — The hymen, like the vagina and lesser 
labia, is covered with stratified squamous epithelium which 
on the inner vaginal as well as the outer vulvar side is almost 
of equal height; well developed papillae can be seen in the epithe- 




FiG. 58. — Terminal Branching of Bartho- 
lin's Glands. The stratified cylindrical epi- 
thelium of the excretory duct, containing vacuoles, 
is gradually replaced by high cylindrical epithe- 
lium (57, 6). (Original.) 



New-born. 



Hymen. 



SPECIAL DIAGNOSIS 103 

lium. — The squamous epithelium rests on a thin groundwork of con- 
nective tissue. — In very rare preparations the excretory duct of 
Gartner's canal can be demonstrated on the hymen. (R. Meyer.) — 

An accurate acquaintance with the urethra is also important 
to the diagnostician. Pieces of tissue are often excised from a hyper- 
trophied urethra, for purposes of examination, and a diagnosis of malig- 
nancy is not infrequently made in such cases. In the female urethra 
the muscular portion, which exhibits an inner longitudinal ^^. , . 

^ ' . ° Histologic 

and outer circular layer, must be distinguished from the composition 

•; ' 1-1 of tlie Urethra. 

mucous membrane; the mucous membrane m the sexu- 
ally mature individual shows stratified squamous epithelium. 
In the higher portions near the bladder a single layer of high 
cylindrical epithelium is described, while other authors speak of the 




Fig. 59. — Urethral Mucous Membrane; Peripheral Extremity. Stratified cylindrical epithelium; 
transverse section of the depression which in part already appears to be solid. (Original.) 

epithelium in this layer as transitional epithelium or modified 
stratified cylindrical epithelium. The mucous membrane contains few 
if any glands, except at the urethral orifice, where a small group of 
glands is found. — These glands exhibit stratified epithelium, and on 
the surface an investment of cylindrical epithelium (stratified cylindri- 
cal epithelium) (Fig. 59). The epithelial proliferation of the glands, 
which often look like crypts, is not infrequently quite well marked. 
Cross-sections and oblique sections are very apt to simulate solid car- 
cinomatous plugs, but the cylindrical epithelium at the surface catches 
the eye and is an important factor in the diagnosis. Special care is 
required in the interpretation of the pictures produced by papillary 
proliferation (caruncle, condylomatous excrescences). — 

Of the urethral glands situated in or at the entrance of the urethra 
Skene's glands, which are present on each side, deserve 
attention. In addition to the crypt-like depressions sur- 
rounding the urethra, which are often multiple and may simulate gland- 
ducts, Skene's glands are sometimes unusually well developed in the 



104 GYNECOLOGICAL DIAGNOSIS 

lower third of the entrance to the urethra. — The urethral mucous 
membrane contains large vessels, especially veins. — The epithelial 
Vesical lining of the urethra in children is exactly as 

Epithelium. above described, except that the dimensions are cor- 
respondingly diminished. — The bladder is covered with stratified 
squamous epithelium (Fig. 60). 

The vagina presents, for microscopic examination, chiefly two 
parts: the stratified squamous epithelium with the subjacent connec- 
tive tissue and the deeper layers of muscle. — The squamous epithelium 
. , resembles that of the external skin and of the vulva, except 

Histologic . _ _ '■ 

Composition of that it docs not contain hair, sweat glands or sebaceous 
glands. The papillee of the epithelial layer are well de- 
veloped, and share actively in the morbid process in cases of inflam- 
matory disease. — The superficial 
r-":^':;^., layers of squamous epithelium do 

not contain horny elements; the 





Fig. 60.' — a. Bladder of a New-born Child at the Level of the Vaginal Portion, b. Stratified 

Squamous Epithelium. (Original.) 

vagina is usually moist and frequently presents the familiar secretion 
known as leucorrhea (fluor alb us). The latter contains normally 
Epithelium nothing but squamous epithelium, a few lymph cells, and 

of the Vagina. mucus corpusclcs. Occasionally the trichomonas is present 
as a parasite, as well as a few bacteria, thrush fungi (oidium albicans), 
and masses of other fungi. — The superficial layer of epithelium in the 
vagina undergoes cornification only in cases of prolapse. The prolapsed 
portion becomes dry, leathery, scales off, and may, when exposed to 
mechanical injury and as a result of the lack of cleanliness, become 
ulcerated. The layer of squamous epithelium invests the entire 
vagina as far as the external orifice, following the many projections and 
folds of the mucous membrane. 

The vagina occasionally contains the vaginal glands which 
have been accurately described by v. Preuschen. They are lined with 
tall cylindrical, or even ciliated epithelium and exhibit the character 
of cervical epithelium (see below). — 



SPECIAL DIAGNOSIS 



105 




W 






-_^.\5i^!>«*t>— 



The normal epithelium of the vagina is altered in hematocolpos: 
instead of the robust, stratified squamous epithelium there is a thin 
layer of epithelial cells without the large superficial squamous elements 
which are normally present; instead we find only a few condition in 
roM^s of small epithelial cells with easily recognizable nuclei. Hematocolpos. 
— In rare cases the vaginal wall appears pinkish and covered with a 
single layer of beautifully ciliated, cylindrical epithelium. This layer 
of epithelium sends down small "gland-like" depressions into the sub- 
jacent tissue. — In these preparations, de'rived from the lowest portion 
of the hematocolpos which protrudes into the vulva, the epithe- 
lium is tall, translucent, 
does not stain, and the nu- 
cleus is situated near the 
base. It shows a "cervical 
character. " By the subse- 
quent conversion into epi- 
dermis (epidermidalization) 
glandular portions may be 
constricted off and remain 
isolated in the depths of the 
tissue. — The vaginal wall 
occasionally contains small 
epithelial (glandular) forma- 
tions, the remains of the 
Wolffian (Gartner's) duct. 
These, like v. Preuschen's 
glands, may form the be- 
ginning of pathologic for- 
mations, such as cysts and 
benign or malignant adenomata. In making the diagnosis the character 
of the epithehum must be studied. — The cysts and glandular 
structures of the vagina, which are occasionally covered with a 
single layer of cylindrical epithelium, may be explained by 
the fact that during the earlier stages of development the 
entire genital tract (vagina, cervix, body and tubes) is covered 
only with a single layer of cyhndrical epithelium. — It is probable that 
these structures (except those which have their origin in Gartner's 
canal, and which can be recognized by their situation in the anterior 
wall) belong, together with the formations of so-called congenital erosion 
(see below), to the same stage of development. — 

The thickness of the epitheHal lining of the vagina varies according 
to age and the individual. In the child and new-born infant, in com- 
parison with the size of the parts, the epithehum is very well developed 




//< 



Fig. 61. — a. Transverse Section through the Vagina of 
A Girl Fourteen Years Old. 6. Transverse Section of the 
Vagina in a New-born Child, c. Vagina, Mucous Membrane, 
Stratified Squamous Epithelium, and Muscularis. (Original.) 



Gartner's Duct 
in the Vagina. 



I 



106 



GYNECOLOGICAL DIAGNOSIS 



and contains large papillae (Fig. 61, c). The boundary line between the 
rate Malphighii and the underlying connective tissue is slightly wavy, 
the epithelium projecting into the connective tissue layer; while in old 
age the epithelium becomes thin and smooth (senile atrophy), in con- 
trast to the rougher surface with numerous projections seen in the 
juvenile vagina. The epithelial layer no longer encroaches on the con- 
nective tissue; on the contrary, the boundary line is rather a little 
concave. T— A transverse section through the vagina of the child and 
new-born infant is more nearly like a square in outline, as compared 
to the cross-section of the sexually mature individual, which is more 
oblong (Fig. 61, a and h). — 

The second constituent, the muscular is of the vagina, is 

made up of several layers 
arranged without definite 





Fig. 62. — a. Vaginal Portion op a Virgin. 6. Vaginal Portion of a New-born Child. (Original.) 



Muscularis of 
the Vagina. 



order. An outer, more longitudinal, and an inner, circular layer are 
distinguished. — The bands of muscle consist of smooth muscle fibres 
which interlace closely with one another; between the 
muscularis and the epithelial layer is a thin layer of rather 
dense connective tissue, while a looser connective tissue connects the 
vagina with the surrounding structures. The lower portion of the 
urethra, however, is intimately attached to the vagina. 

In the uterus three parts must be sharply distinguished: the 
vaginal portion, the cervix, and the body. Each segment is 
sharply separated from the next. Once the parts have become difTer- 
Composition of eutiated in fetal life, the three sections remain absolutely 
the Uterus. distiuct duriug the entire life of a woman, both 

during pregnancy and inflammatory and malignant altera- 
tions. Each individual portion has its own special epithelial covering, 
and in part also its own tissue; even the changes (especially the malig- 



SPECIAL DIAGNOSIS 107 

nant changes) which occur show, in the main, a more or less specific 
character in the individual segments. — The cervical canal begins at the 
external os and extends to the internal os; this in turn forms the 
beginning of the uterine cavity (cavum corporis uteri), which in sagittal 
section has the appearance of a canal. — 

The vaginal portion in a sexually mature individual is covered 
with stratified squamous epithelium, which is the continuation of that 
in the vagina. In the deepest layers the cells represent short cylinders, 
and near the surface are converted into squamous ele- (a) Portio 

ments. — The epithelium contains numerous slender papillae Vaginalis. 

which, as the result of abnormally increased vascularity from irritation 
or inflammation, soon alter their shape and size. — The epithelial cover- 
ing is intimately attached to the tissues of the vaginal portion; there 
is no mucous-membrane tissue (subcutaneous connective tissue) be- 
tween the epithelium and the tissue of the vaginal portion (Fig. 62). — 
Proliferations of the epithelium grow directly into the 
tissue. — The stroma of the vaginal portion consists of firm 
connective tissue made up of robust fibres; elastic fibres have also 
been described. — The vessels pass from below in a straight stroma of 

course like columns to the superficial layers, where they Po^tio vagmaUs. 
break up into branches, and return as veins. — The central portion of 
the stroma contains a great deal of muscular tissue derived from the 
cervix or from the body, usually in company with vessels. A few muscle 
bundles often accompany the vessels to the cervix. — The stratified 
squamous epithelium in the vaginal portion in many cases (par- 
ticularly in virgins) ends at the external os. The whitish, firm epi- 
thelium ceases abruptly and is replaced by the more delicate Epithelium of 
cylindrical elements. The whitish coloring of the squa- Po^tio Vaginalis. 
mous epithelium contrasts with the pinkish color (immediately succeed- 
ing) of the cervical mucous membrane, which is covered with cylindrical 
epithelium. Exceptionally, under normal conditions, the stratified 
squamous epithelium may extend a short distance into the cervical 
canal; under abnormal conditions, after labor tears, the epithelium 
may undergo a great many changes (see under ectropion, epidermidali- 
zation). — The vaginal portion of the new-born infant differs from 
the somewhat flattened, smooth vaginal portion of the sexually mature 
virgin by its slightly conical shape. The thickness of the portio vaginalis 
squamous epithelium varies in different individuals. The of tii^ New-bom. 
papillae are well developed and the vaginal folds or projections 
(vaginal type) can be seen not infrequently even with the naked eye, 
and quite often in the microscopic picture. Sometimes the epithelium 
covering the vaginal portion is exceedingly thin and made up of only 
a few layers; as the external os is approached, it becomes thinner by 



108 



GYNECOLOGICAL DIAGNOSIS 



Congenital 
Erosion. 



"sudden leaps." (Fig. 63, a.) From the vaginal wall downward toward 
the portio vaginalis the epithelium diminishes in thickness; indeed 
cylindrical epithelium of a slightly papillary character may even be 
present on the outer side of the vaginal portion before the external os 
is reached (so-called congenital erosion, see Fig. 63, a and h). — 
Strands of this cylindrical epithelium may extend into the 
vaginal vault. — -Even if the stratified squamous epithelium 
has not yet reached the external os, this makes no change in the shape 
of the vaginal portion as compared with the cervix and its characteristic 
cervical character. — The squamous epithelium encroaches on the cervical 
canal much more frequently in children than in adults. — The cervical 
canal in the new-born is often so greatly dilated by mucus at the external 
OS that the tip of the little finger can be inserted. New-born infants 

rarely exhibit a contracted 
_^ :;«c<?e» \i >.^ ■ external os, which is not infre- 

'.^v^liir^' '/P sS^ quently observed in adults. AA'e 





Fig. 63. — a. Vaginal Portion op a New-born Child with Congenital Erosion. 6. Cylindrical Epithe- 
lium gradually becoming converted into stratified squamous epithelium. (Original.) 



cannot speak of a conge nitally narrowed external os. — The 
differences in the epithelium covering the vaginal portion of the new- 
born infant are explained by the development of that structure. The 
cylindrical epithelium, which originally covers the vagina, as it pro- 
gresses from the outside, and the lumen of the vagina is increased, 
becomes stratified; while the epithelium at the introitus and lower 
portion is already quite robust, the upper portion of the tube may con- 
tain only a narrow zone of squamous epithelium; or the epithelium may 
even be of the cylindrical variety (see above, congenital erosion). 

The surface of the cervix, which begins at the external os, is 
covered with tall and narrow cylindrical epithelium — short along the 
top of the ridges, and taller at the bottom of the depressions. — 
The epithelial cells are not sharply differentiated from 
one another. — The boundary line is delicate and finely 
dotted. The epithelium is often so translucent that it is at first over- 
looked by the inexperienced, especially under a low power. — The cell- 



(b) Cervix. 





SPECIAL DIAGNOSIS 109 

body does not stain at all (especially when alum-carmine is used), and 
the outline of the cells very faintly. The nuclei alone stain intensely 
and usually have the shape of a long oval; when the cells are tall, 
they are correspondingly narrow, and spherical in the shorter 
elements; they are finely granular and basally situated close 
to the lower boundary of the cell. 

The character of the cervical epithelium varies at different ages; 
while in the sexually mature organ the nuclei are almost always 
basally situated, in children and in new-born infants they 
are quite often situated higher up in the lower third, or in some places 
even higher. — Owing to the many ridge-like projections or folds (plicae 
palmatge), which in cross-sections look like papillae, the surface of 
the cervix is unequal, with shallow depressions; the surface appears wavy. 

In addition to these elevations, which simulate papillae (cross- 
sections of the ridge-like or fold-like processes), true papillary pro- 
liferation also occurs, especially when 
the tissue is irritated, as in inflammatory 
processes. — The epithelial cells, which on 
the surface are crowded closely together 
and are uniform in size, and consequently 
are often very narrow and high, exhibit 

a very graceful formation in the papillary ..AVco.TM^/JZrr.VclY:™ 
proiections (Fig. 65) : so-called palisade cells and centbally situated, ting- 

ir J \ o / 1 IBLE Nucleus, b. Epithelium of the 

or fan-like formation. When the Cebvix with basal nuclei. The cells 

do not stain. (Original.) 

projections are close together, a very 

pretty picture is produced by these serried ranks of epithelial cells, 
which seem actually to interlace, and thus produce the characteristic 
palisade, bundle, or fan-like formation. — During sexual maturity 
the epithelial cells are ciliated, although not so regularly as in the 
case of the uterine epithelium. The ciliated epithelium can be 
demonstrated only in fresh preparations. — The epithelium cover- 
ing the surface of the cervix follows the various depressions 
of the mucous membrane (cervical glands). The latter exhibit 
various forms, such as large crypts; glands suggesting the race- 
mose type, owing to the various ridges and projections, 
transverse or flat sections exhibit a peculiar and very grace- 
ful formation in the microscopic preparation (Fig. 65, a); portions of 
epithelium apparently project into the lumen and interlace with one 
another. This arrangement of the epithelium corresponds 

1 c 1 1 Ti • • 1 • 1 1 T • 1 Flask-shaped 

to the fold-like projections which subdivide and spread out cervicai 

in various directions. — In the second place, we distinguish 
flask-like depressions, narrow at the entrance like a flask, from which 
they take their name, and with a slight dilatation below. Under 



110 



GYNECOLOGICAL DIAGNOSIS 



Tubular 
Glands (Antler- 
formation). 








m 

:^:-:\ 



normal conditions the epithelium covering their surface is smooth and 
exhibits no elevations. — Third, we have, in addition to the crypts and 
flask-shaped depressions, the tubular glands which sub- 
divide repeatedly, then undergo further branching, and 
thus produce a picture which has been compared to the 
antlers of a stag. These tubular, branching formations in the normal 
state, and sometimes also when hypertrophied, are narrow (Fig. 66) ; 
the glandular elements are almost in contact with those on the opposite 
side, leaving only a narrow lumen. — The first two formations are found 
;'iji'4^ ' -^ - -- more commonly in the cer- 

SS^^!?^^^ j'^^^s^i^'T-igS^^^ ^i^ of "the infantile uterus; 

the third, in that of the 
sexually mature organ. — 
In the latter the cylin- 
drical epithelium usually 
begins abruptly at the ex- 
ternal OS, particularly if 
the opening is nar- 
row. In new-born 
infants a portion of 
the cervix may also 
be covered with 
stratified squamous 
"i^— epithelium, as al- 
ready mentioned 
above, and the cyl- 
indrical epithelium 
may begin a little 
higher up. The 
boundary line be- 
tween the two kinds 
of epithelium can be 
distinctly recognized with the unaided eye by the opaque, whitish color of 
the stratified squamous epithelium, as compared with the delicate pink of 
the mucous membrane that is covered with cylindrical epithelium. — In 
adults the cervix, i.e., the part beyond the external os, may be covered 
with stratified squamous epithelium in dilatation of the cervix 
after parturition, in ectropion of the mucous membrane 
following pathologic processes, and later transformation of the cylindrical 
epithelium into stratified squamous epithelium (epidermidaliza- 
tion). — The stratified squamous epithelium may cease abruptly, and the 
cylindrical epithelium begin without any transitional zone; indeed the 
stratified squamous epithelium quite often appears to be pushed under 



m^ 



,,^01^0^. 






m 






^^\um^^^^^mm, 




ft// 



■^^:^^At^ 



--'^Oi ^IT^fvV^ 



Fig. 65. — a. Cervical Mdcous Membrane: Tubular and racemose 
glands. 6. Cervical Epithelium with Basal Nuclei. The cell-bodies 
do not stain. (Original.) 



SPECIAL DIAGNOSIS 



111 



So-called 

Cervical 

Goblet-cells. 



the cylindrical epithelium so that the latter covers the former for a 
short distance. — In epidermidalization the transition from cylindrical 
to stratified squamous epithelium is often quite gradual; two or three 
or more epithelial elements gradually change their shape and pile up 
on one another. 

The cervical mucous membrane, particularly in the new- 
born infant, often contains a profusion of "goblet-cells" 
which are very conspicuous by their shape in the micro- 
scopic section (appearing like spherical gaps or vacuoles). 
— These so-called goblet-cells are not intended for the production 
of the cervical mucus, but rather owe their existence to a degener- 
ation or destruction of the luxuriating 
epithelial cells. In some uteri the goblet- 
cells are almost entirely wanting, while in 
others they are found in large numbers. — 

The uterine mucous membrane (mucosa 
corporis uteri), both macroscopically and 
microscopically, in the sexually mature as 
well as in the infant, has a smooth sur- 
face compared to that of the mucous mem- 
brane of the cervix. In the sexually mature 







woman it is from 1 to 2 mm. in thickness :f^^^^f'^'/J'>%\^\' 












Fig. 



— Cervical Gland (antler-for- 
mation). (Original.) 



and, macroscopically as well as microsco 
pically, is sharply differentiated from the 
muscularis. The mucous membrane is inti- 
mately connected to the muscle and is 
immovable. — Even in the microscopic pic- 
ture the cytogenous tissue of the uterine 
mucous membrane, with its glands, is 
sharply differentiated from the muscularis 

by a practically straight or slightly wavy boundary line. — The 
conditions are the same in the infantile uterus, although they are 
not quite so conspicuous. — Under morbid irritation the thickness of 
the mucous membrane may increase tenfold, and the mucous membrane 
with its glands may dip deep down into the muscular layer (see below). — 
The uterine mucous membrane consists of (1) surface epi- 
thelium and epithelial depressions (uterine glands); and 
(2) the stroma, which accommodates both blood- and 

.■,-,..., Corporeal 

lymph- vessels. The surface epithelium is cylindrical Epithelium in 
and both shorter and broader in comparison with the tall 
cylindrical epithelium of the cervix; it is also somewhat shorter at the 
surface than in the deeper portions of the mucous membrane. While 
the cells are less sharply defined than those of the cervical epithelium, 



112 



GYNECOLOGICAL DIAGNOSIS 




the outlines of the individual elements are nevertheless distinctly- 
visible. — The cell-body is finely granular and contains an approxi- 
mately oval, granular nucleus. — The latter is situated centrally. 
Both nucleus and cell-body are readily stained.— 

The position of the nucleus and the staining proper- 
ties are characteristic and serve to distinguish uter- 
ine from cervical epithelium. — The cylindrical epithelium of 

the uterine mu- 
cous membrane is 
approximately 
oblong, becoming 
more cuboidal, 
however, as the 
surface is ap- 
proached. In 
transverse or flat 
sections the cells 
appear hexagon- 
al, while in longi- 
tudinal sections 
the cylindrical or cuboidal shape 
is more conspicuovis. Flat sec- 
tions exhibit beautiful hexagons 
arranged in the form of a mosaic. 
— Oblique sections show transi- 
tional pictures between the hex- 
agonal and cylindrical forms. 
The epithelium is built up 
somewhat like the cells in 
a beehive. The surface epi- 
thelium! of the uterine mucous 
membrane in the sexually ma- 
ture organ differs somewhat from 
that of the infantile organ. In 
the former the cells are covered with cilia which, according to 
M. Hofmeier, have an outward (distal, peripheral) movement. The 
Ciliated movements of the ciliated epithelium, which may be 

Border. Compared to the waving of a corn-field, are extremely 

active and can be seen only in recent specimens. Rarely, the 
ciliary capping may be demonstrated in hardened specimens. — In 
certain forms of hyperplastic endometritis the ciliated border appears 
to be more robust and more resistant (and may be recognized in 
alcoholic preparations). — ■ 






~f'\T't:s!!iii^. 




Fig. 67. — a. Cross-section Through the Corpus 
Uteri of a New-born Infant. Uterine mucous mem- 
brane with the beginnings of uterine glands. The lateral 
portions of the section include the tubes and the ovaries. 
b. Cylindrical, finely granular, deeply staining epithelium 
covering the surface of the body of the uterus. (Original.) 



SPECIAL DIAGNOSIS 



113 



Changes — the 
Climacteric. 






In the climacteric the cilia are lost, although they often survive 
the cessation of menstruation by a considerable time. The ciliary 
movements in some cases do not cease until old age 
begins. — In the climacteric, or occasionally sometime after 
the cessation of the menses, the cylindrical epithelium of 
the surface of the uterus (sometimes also that covering the epithelial 
depressions in the mucous membrane) becomes shorter, loses its tingi- 
bility, and is transformed into cuboidal elements like squamous epithe- 
lium. — The proliferating power of the uterine epithelium is sometimes 
incredibly great, even during the first years after the menopause. — A 
sharp distinction must be made between the climacteric and old age 
in their relation to the life-history of the uterine mucous membrane. — 

The cylindrical epithelium of the uterine surface dips downjnto the 
mucous membrane, forming glandular structures — the uterine glands. 
— In embryonal life the 
surface of the uterus (like that /§ 

of the cervix and, in the begin- 
ning, also that of the vagina) 
is covered with a single layer 
of cylindrical cells. — Long 
after the vaginal portion has 
become differentiated from the 
other segments, apparently 
by a slight kinking of the 
lumen and of the covering of 
cylindrical epithelium, and 
long after cervical glands have 
developed in large numbers, a few shallow, insignificant depres- 
sions appear in the body of the uterus. — The uterus of the new- 
born infant shows two kinds of depressions: First, 
small tubular depressions resembling small uterine glands 
of the sexually mature individual, except that they are shorter and 
occupy barely a third, or rarely one-half of the mucous membrane; and 
second, short racemose invaginations, with two or even three acini 
(lobules), apparently opening at a single point through a single 
excretory duct. The epithelium covering the floor 

» , . . . Uterine 

of these depressions is occasionally character- Giandsin 

istic. AVhile the surface and upper portion of the gland- 
ular structure exhibits a typical uterine (corporeal) character, the 
epithelium at the bottom of the depressions is translucent, does not 
stain well, and the nuclei are basally situated, producing the picture 
of the cervical type (Fig. 68). — During pregnancy the uterus of 
the sexually mature individual also occasionally exhibits this peculiar 




Fig. 68. — Uterine Glands of New-born lNr.A.NT: 
Showing the epithelium with centrally situated nuclei stain- 
ing at the surface, and at the floor of the depression assuming 
the cervical character. (Original.) 



Uterine Glands. 



114 



GYNECOLOGICAL DIAGNOSIS 



Uterine 
Glands in 
Longitudinal 
Section. 



condition of the epithelium — distinctly corporeal at the surface and 
cervical at the bottom. — 

As sexual maturity is reached, the picture of the uterine 
mucous membrane rapidly undergoes a change. The mucous membrane 
increases in thickness; but the principal change lies in the appearance 
of regular, serried ranks of tubular glands (uter- 
ine glands), which extend from the surface 
to the muscularis. The glands are usually parallel 
to one another, whether their course be straight or slightly 
tortuous (Fig. 69). Near the entrance they are apt to be narrow so that 
the opposed cells are almost in contact; as they descend, the lumen 
becomes somewhat wider and the fundus of the glands is slightly spheri- 
cal, or sometimes turned 
on itself, running parallel 
with the muscular layer for 
a short distance, or rarely 
dipping down slightly into 
the interstices of the mus- 
cular tissue. While the 
direction of the glands is in 
the main practically per- 
pendicular to the surface, 
the arrangement at the 
cornua and at the c e r v i c o - 
f undal flexure is slightly 
radiating, to compensate for 
the curve of the gland. — In 
addition to glands exhib- 
iting a straight or slightly tortuous course, corresponding to lateral 
protrusions and indentations, cork-screw varieties (pendulum, circular,, 
and screw-like forms) are also observed. — The glands usually 
have a solitary duct, although occasionally some may be 
provided with two; sometimes the duct, which is usually 
single, undergoes division so that we have two glands 
corresponding to a single excretory duct. — In cross-section (Fig. 70) 
the uterine glands appear spherical, oval, of uniform width, and sepa- 
rated by equal intervals from one another, the distance being normally 
Uterine Glands cqual to from 2 to 2J transvcrsc diameters of the glands, 
in Cross-section, j^ cross-scctions of the glands the cells appear arranged in 
circles, those at the base, in accordance with the circular arrange- 
ment, being somewhat broader than those at the upper extremity. 
The lumen of the gland is equal in width to about one-half to one 
cell-length, and of the same height. — Each gland has its vitelline 




Fig. 69. — Normal Uterine Mucous Membrane: The 
uterine glands are slightly reflected at the edge of the muscular 
layer. The uterine glands also undergo division or they are 
provided with branching ducts. (Original.) 



Uterine 
Mucous 
Membrane of 
the Sexually 
Mature Woman. 



SPECIAL DIAGNOSIS 115 

mem bran a propria, which is difficult to demonstrate; if the cell is 
carefully macerated in watery serum the entire membrane may some- 
times be brought out. — The glands themselves are, in addi- Membrana 
tion, surrounded by a network of spindle-shaped Propria, 
connective -tissue elements with somewhat oval nuclei; these 
are in close contact with the membrana propria, and with the latter 
form the envelope of the glands; outside of this is found the stroma 
with its round cells. — 

After the climacteric — at the beginning of old age — the uterine 
mucous membrane, owing to atrophy of all its constituents (epithelium, 
as well as connective tissue) undergoes considerable changes. It be- 
comes much thinner, the boundary line between it and the muscular 
layer is more irregular and, instead of representing a straight line, 
convex toward the surface (to- 
ward the lumen of the uterus). 
— The surface epithelium is 
shorter, cuboidal, less easily 

stained, and pale (see above). ^^^^^^'P.^^'- ^-i 
The glands are few in number, :.^m»S^^^^]Si 
their course is quite irregular ^^ ^ ^f Jti^ '-■^■^ 




i;«k»_ 



and parallel to the surface; ■^■*l^*»ijfjf|«'i-^ i-^lot* 

here and there are seen small ■*^*«f#|(T»^ ^-^S \ 

gaps in the tissue contain- t'*<^|'t'w': "^^v^v .^' J 

mg epithelial cells m process ^-^^^ '^^-''*''=>^ 

of decomposition. The glands Fig. 70.— uterine Mucorrs membrane: showing the 

nr^r^any nl'^^mr^^aA " Q + T/-VT-, V>i /» " cyhndrical epitheUum With Central nucleus; opening of a 
appear Crumpiea, atlOpniC. uterine gland; cross-section of a uterine gland. (Original.) 

The second constituent 
of the uterine mucous membrane, next in importance to the epithelium 
(parenchyma) is the stroma, which accommodates the epithelial struc- 
tures and the lymph- and blood-vessels. — In the stroma we distinguish 
the delicate retiform framework (intercellular substance) and the cellular 
elements (stroma cells). The retiform framework is not 

, . . ... . Stroma of 

always distinct, but under certain conditions, such as slight the uterine 

edema of the mucous membrane or dysmenorrheic endome- 
tritis, it may be quite well seen. — The stroma cells are round and resemble 
lymph-corpuscles. Under normal conditions the cell-body of these 
round cells can barely be seen or is invisible. The cell 
is completely filled by the round, well-stained nucleus. 
In addition to the spherical stroma cells we find in a normal mucosa, 
usually only in the neighborhood of vessels in the deeper layers of the 
mucous membrane, and surrounding the glands, spindle-shaped elements 
which can often be recognized only by their oval nuclei. In a slightly 
edematous mucosa the delicate processes by which the individual stroma 



116 



GYNECOLOGICAL DIAGNOSIS 



elements are connected may be occasionally seen. — Owing to the similar- 
ity of the stroma cells to the cells of the lymph-glands, the uterine mucous 
membrane is designated a lymphoid, adenoid or cytogenous tissue. — The 
stroma of the infantile uterine mucosa consists of small round cells, 
as in the period of sexual maturity. After the climacteric, the mucous 
membrane is converted into the senile atrophic endometrium — 
the stroma cells disappear in part, while others are converted into 
spindle-shaped elements which arrange themselves in rows and produce 
a fibrous, cicatricial appearance. The mucous membrane presents the 
appearance of chronic interstitial change or cirrhosis (sclerosis). — The 
stroma, parenchyma, and epithelial structures atrophy. — Often a prema- 
ture atrophy is observed (atrophia senilis prsecox, senescentia prsecox). 





/^:,:e^ri>„-v 







Menstruation. 



Fig. 71. — Uterine Mucous Membrane during Menstruation, with Epithelial Hematomata. (Original.) 

With the occurrence of sexual maturity and 'pari passu with the 
development of the uterus and its mucous membrane — not before, 
and often not until some time afterward — the regularly recurring 

physiologic process of menstruation (catamenia) begins. 

— Several stages may be distinguished in menstruation by 
anatomical and microscopic examination: First, there is great con- 
gestion of the vessels and, with it, swelling of the mucous membrane: 
the stroma becomes saturated with serum and loosened. — The second 
stage is that of hemorrhage (by diapedesis and rhexis) : the 
blood is poured out into the tissue, on the surface of the uterine cavity 
and into the glands. Here and there on the surface of the epithe- 
lium there are seen irregular prominences of the epithelium due to 
subepithelial hemorrhage (the epithelial hematomata of Geb- 
hard, Fig. 71). These hematomata may rupture and evacuate their 



SPECIAL DIAGNOSIS 117 

contents into the uterine cavity, and the epithehum may again become 
attached to the surface. — The hemorrhage into the tissue of the mucous 
membrane is pronounced in the upper portions near the surface 
epithelium. In microscopic preparations the mucous membrane every- 
where in the upper portion appears brownish-red, in contrast to the 
more anemic, deeper lying portions, which appear pale. — The process 
of diapedesis and hemorrhage is followed by that of absorption of 
the blood which has been poured out into the tissue and has not been 
discharged outside of the body. Several days after menstruation 
granular, yellowish blood-pigment is found; this also disappears, how- 
ever, in a short time, and the mucous membrane returns to its normal 
condition in a few days. — The epithelial cells which are destroyed or 
separated by the formation of hematomata or by the hemorrhage itself, 
are soon renewed or reattach themselves to the surface. — 

Complete expulsion of the mucous membrane and 
systematic renewal of large masses of epithelium or con- 
nective tissue does not take place during menstruation, 
as was formerly supposed. — Physiologic processes (men- 
struation without loss of substance) must be sharply ^t°At™nded 
distinguished from pathologic processes (membranous ""^o^lduioTa"^ 
endometritis), in which large portions, or even the upper 
layer of the entire uterine mucosa, are expelled, and the evacuated 
membranes represent a complete "cast" of the uterine cavity. — It is 
not correct to speak of gradual transitions or differences; in the case 
of the intestine the normal activity, from the etiologic standpoint 
alone, must be distinguished from pathologic (dysenteric) processes. — 

The so-called menstruation of new-born infants is an 
interesting phenomenon; a bloody discharge lasting several days some- 
times occurs. — The mucous membrane (judging from the very rare 
accidental findings) microscopically presents a condition Menstruation of 
entirely analogous to that which has been described in ^^^ New-born, 
the sexually mature individual. The diapedesis, in one case which has 
been observed, appeared to be very extensive and involved the entire 
mucous membrane, just as is in adults. — 

A second alteration of the mucous membrane, which, like men- 
struation, must be regarded as a physiologic process or con- 
dition — the changes due to pregnancy — will be discussed separately 
(see below). 

After the mucous membrane of the uterine body, the 
cervix and the epithelial covering of the vaginal portion 
have been studied, there remain the constituents of the uterine wall 
as well as of the peritoneal covering, and here also a division into 
body, cervix, and vaginal portion is to be made. The tissue of the 



118 



GYNECOLOGICAL DIAGNOSIS 




uterine body is chiefly composed of muscle. The connective tissue 
frameworlc is insignificant compared to the massive development 
of the muscle fibres. — Microscopically the musculature consists 
of smooth muscle fibres which in longitudinal section represent 
spindle-shaped, narrow elements with uniform, rod-shaped nuclei. 
Musculature I^ rare cases, under very great magnification, a fine pat- 
of Corpus uteri. ^^^.^ ^^^^ j^g made out in the muscle elements or their 
nuclei in the no n -pregnant state. In the gravid uterus, and 
occasionally in myomata, which may, although in rare cases, produce 
an increase of the muscular elements in the organ, the greatly en- 
larged muscle fibres contain a finely granular protoplasm and one or 
two nucleoli in the enlarged, narrow, oval nucleus. — The muscle fibres of 

the sexually mature 
organ are arranged 
in bundles; the 
individual fibrets are 
arranged regularly 
in the same direc- 
tion within the bun- 
dles and undergo 
division, producing 
the picture of radi- 
ation and thus em- 
bracing other bun- 
dles. The fibres 
appear to form an 
i nt e rlacing net- 
work, like felt. The 
bundles themselves run in different directions. Hence the muscle 
bundles appear in a great many different planes — in the microscopic 
section — transverse, longitudinal and oblique. In transverse 
sections the muscle bundles form small, spherical structures 
corresponding to the transverse section of the muscle elements, 
and therefore appear like an aggregation of small, approximately 
round cells, except that the outlines are usually not so distinct as in 
the case of genuine round cells. The transverse sections of smooth 
muscle elements are also characterized by the somewhat greater 
refraction of the sarcolemma, and the transverse sections of the nuclei 
are often wanting because all the muscle elements are not always 
cut in the middle and the nuclei therefore do not appear in all the sec- 
tions. — In oblique sections transitional forms between longitudinal and 
cross-sections are seen: short, spindle-shaped figures with narrow, and 
often spherical nuclei. — 







Fig. 72. — Musculature of the Uterine Body : Longitudinal and 
transverse muscle bundles. (Original.) 



SPECIAL DIAGNOSIS 119 

The arrangement of the bundles and strands of muscle fibres 
with respect to one another in the sexually mature organ 
appears to follow no rule whatever. The different bundles appear to form 
a closely interlacing network, like felt. There is no uniform arrangement 
in layers (circular and longitudinal layers, as in the intestine), although 
it is customary to describe in the uterus an outer longitudinal and 
an inner circular layer, and between the two the remaining interlacing 
and crossing muscle bundles — the general mass of the musculature. — The 
history of the development of the uterus shows that the muscu- 
lature is derived from a number of regular layers (von Hoffmann), which 
survive in the tube. In the sexually mature organ the theory of regu- 
larly arranged longitudinal and circular layers is untenable. — 

Several muscle bundles unite to form groups, and within 
the groups the individual bundles interlace and cross one another 
in various directions. — The musculature is composed of large and small 
groups of muscle bundles in close opposition, and the groups are inti- 
mately connected by stroma. — A section through the musculature of 
the body of the uterus represents the picture of a uniformly interlacing 
tissue, exhibiting here and there whitish or asbestos-like strands which 
consist of longitudinal sections (longitudinal muscle bundles). — 

Under normal, as well as under pathologic conditions the 
apparently irregular arrangement of the musculature of the uterine 
body may be replaced by a uniform arrangement in layers — a lamellar 
arrangement. As the uterus enlarges through the growth 

_ □ o c3 Lamellar Ar- 

of the fetus during pregnancy or the presence of a myoma, rangement of the 

, , ,.,. ,. ._. -, Musculature 

the musculature, which is apparently inextricably tangled, when the uterus 
unfolds and becomes arranged in uniform layers (longi- "^ '^a-^se . 
tudinal layers, lamella") in the case of pregnancy throughout the 
organ, or in myoma uteri only around the tumor. In the case of 
very large, or multiple, fair-sized myomata the structure of the entire 
body sometimes becomes lamellar. It is owing to this lamellar 
metamorphosis of the musculature, usually around the 

^ ' -^ So-called Cap- 

myoma, that the tumor can be enucleated (so-called capsule- suie-formation 
formation of the myoma). The lamellae are thin and 
often can be readily separated and torn. The myoma is connected to 
the musculature by individual lamellae. By circumscribed prolifer- 
ation in the muscular layers (lamellae) which are connected with the 
myoma the tumor enlarges (growth by apposition) and is also more 
readily isolated. — Finally, especially after growth has ceased, the 
pressure of the myoma on the nearest individual muscle layers may 
produce a certain atrophy of these layers, and in this way a kind of 
encapsulation may be simulated. True encapsulation (" capsule- 
formation") does not occur in myomata. — 



120 GYNECOLOGICAL DIAGNOSIS 

The lamellar structure which results from enlargement of the 
uterus is not composed entirely of parallel muscle layers; with a little 
care it is possible everywhere to distinguish bundles running obliquely 
Muscle- from the longitudinal lamellse and strands of tissue 

rhomboids. connecting adjacent longitudinal layers. In 

this way the so-called muscle rhomboids are formed. — 
These muscle strands connecting the longitudinal lamellae, and the some- 
what different arrangement of the musculature in the muscle lamellae 
and connecting strands of muscle, explain the various effects that are 
produced when the muscle contracts. — In the gravid uterus it may be 
shown that the closely packed muscle lamellae in the upper 
portion of the uterine body are firmly attached to the perito- 
neum, whUe in the lower portion of the body, the so-called lower 
uterine segment, only a few muscle lamellae are thus attached; hence 
firm fixation of peritoneum above, and loose connection 

Line of Firm 

Attachment of with the orgau below. — The boundary between the loose 
attachment of the muscle lamellae and the closely packed 
lamellae which are firmly attached to the peritoneum is called the 
line of firm attachment of the peritoneum. (F. A.) — 
Musculature of The samo ill-defined character is observed in the muscle 
the New-born. buudles of the uterus of the child and of the new- 
born infant. The strands of muscle fibre are much thinner and the 
microscopic picture is therefore much less complex. — After the climac- 
teric, in old age, the muscle undergoes marked atrophy. 
The connective tissue becomes apparently increased and 
the organ reduced in size. — The blood-vessels often show marked thick- 
ening of their walls (sclerosis), besides myxomatous degeneration. — 

The cervical tissue consists for the most part of connective 
tissue; the stroma of the cervix receives strands of muscle fibres from 
the body, which divide and enter the firm connective tissue in various 
directions. Immediately underneath the mucous mem- 
brane of the cervix distinct strands of muscle bundles can 
be demonstrated. In the outer portion these strands are exclusively 
longitudinal and merge with the muscular tissue of the vagina. In the 
middle of the cervix, and becoming less numerous as the surface of the 
vaginal portion is approached, there are regular strands of muscle 
fibres, usually, however, only where there are blood-vessels. — The wall 
of the cervix does not undergo a definite change, particularly a lamellar 
change, during pregnancy, as in the case of the uterine body. 
Tissue of the The vagiual portion (see above) consists of firm con- 
Portio Vagmahs. ^gg-tiye tlssuc. Containing a few muscular elements. The 
connective tissue lies underneath the stratified squamous epithelium 
and is made up of uniform fibres with abundant nuclei. In deep layers 



SPECIAL DIAGNOSIS 121 

more robust and wavy masses of connective tissue, as well as some 
strands of muscle tissue are found. In the layers near the epithelium 
elastic fibres have been demonstrated (Diihrssen). 

The arterial vessels in the mucous membrane of the body of 
the uterus are generally but poorly supplied with muscular tissue; after 
pathologic processes, however, the walls of the vessels, vessels: 

which are often quite tortuous, may undergo thickening. — '■^^ Biood-vesseis. 
In the cervix as well as in the vaginal portion the walls of the blood- 
vessels are better developed. — The uterine body of the child and 
of the new-born infant contains wide, well-developed, often cav- 
ernous vessels in the layers underneath the peritoneum. — The same pic- 
ture of ''cavernous" tissue is not infrequently seen in the tissues of the 
vaginal portion, particularly the layers situated near the epithelium. — 
The uterus is abundantly supplied with lymphatics, (b) Lymph- 

which in the mucous membrane take the form of simple vessels. 

clefts. In the tissue of the individual portions of the organ they are 
covered with endothelium and unite to form large lymphatic trunks on 
both sides of the organ (see lymphatics of the uterus). 

The greater part of the uterus is covered with peritoneum which, 
like the remainder of the membrane, is covered with epithelium (endo- 
thelium) ; the latter may be completely cylindrical, and glandular 
depressions may extend beyond the peritoneal tissue into 
the muscularis (Rob. Meyer). — The peritoneum consists 
chiefly of connective tissue, with a few longitudinal smooth muscle 
fibres which, near the tubes, become circular. — The peritoneal cov- 
ering of the uterus in the sexually mature organ is, for the most part, 
firmly attached; on the anterior wall the boundary-line 
of firm attachment forms a parabola, the apex of which is Atfa^cWnt! 
lowest in the median line, about 1 cm. above the region of ^^^ *° *■'*' 4?*iT 

' o rior Wall. 

the internal os, while the two lateral curves pass to the 
region underneath the round ligament. On the posterior wall the 
line of firm attachment of the peritoneum is much lower; here the apex 
of the parabola is usually at the level of the middle of the (b) to the 

cervix, and the lateral curves pass to the region underneath Posterior waii. 
the ovarian ligaments. In the remaining portions of the uterus 
covered with peritoneum the attachment is loose. — 

The peritoneum is intimately connected with the 
uterine muscle. In the gravid uterus the lamellar strands of muscle 
fibres are seen to originate in the peritoneum, entering the 

° \ 1 • n AT Attachment of 

uterme wall from above downward and mward. At the uterine Muscle 
point where the peritoneum is firmly attached, the ° *"" °'^^"'°" 
origins of the muscle lamellae are seen close together; below, where 
the attachment is loose, only a few large muscle lamellae, widely 



122 



GYNECOLOGICAL DIAGNOSIS 



separated from one another, without much tendency to interlace, are 
seen. Above, numerous small rhomboids of muscle tissue; below, 
a few large muscular rhomboids. — 

This firm and loose attachment of the peritoneum can be seen 

also in the uterus of the child, as well as of the new-born 

infant, iust as in the sexually mature organ the line of 

Firm and Loose ' '' . . "^ ° 

Attachment of firm attachment is situated a little above the level of the 
/ internal os. — That part of the uterine body which 
lies between the line of firm attachment of the perito- 
neum and the internal os is described separately. During 
Lower Uterine preguaucy tliis portiou increases with the size of the uterus 
Segment. ^^^ ^g kuowu as the lowor uterine segment. (The 

lower uterine segment will be referred to later). — 

The uterus further presents for study Gartner's ducts, which 



i.i'Jit. 








■^ 



m 



t!^H 



Gartner's 
Ducts. 



Fig. 73. — a. Transverse Section through the Cervix of a New-born Child. On each side of the 
lumen of the cervix Gartner's ducts subdivide laterally, b. Under higher magnification the cervical mucous 
membrane with cervical epithelium does not take the stain (in this section the nuclei are not regularly situated 
near the base). Gartner's canal with epithelium resembling that of the body of the uterus. (Original.) 

are not constant, or their remains. They enter the uterine muscle from 
the side (at, or a little above, the level of the internal os) when they are 
well preserved; are deflected slightly downward and in- 
ward, and pass over the vaginal vault in a slightly recurrent 
arch to the vagina; here they deviate to one side and slightly forward, 
and end in their orifices at the level of the hymen. Sometimes Gartner's 
ducts are merely simple canals, and occasionally a canal is 
present on one side only. Sometimes the ducts form remarkable 
ramifications, due to lateral ducts that are given off and subse- 
quently undergo subdivision; the ramifications have slightly dilated 
extremities (Rob. Meyer, Fig. 73, a.) The epithelium is cylin- 
drical and resembles the uterine epithelium in the posi- 
tion of the nucleus and its staining qualities. Gartner's 
duct is surrounded by an envelope of small-celled connective tissue. — 
The malignant degenerations of the epithelial constituents are inter- 
esting (Rob. Meyer). Some vaginal c-ysts, which are seated in front and 
laterally, are attributed to Gartner's ducts. — 



SPECIAL DIAGNOSIS 



123 



Tubes. 



'(■fS 



^^u 



&> 



•'7=' 




vi^ 



I 



The tubes present first a peritoneal covering; second, a rich 
layer of muscle tissue, longitudinal near the outside and circular within; 
and third, the mucous membrane. — The character of the tube varies 
in its different segments. Aside from the interstitial por- 
tion (the portion within the uterine wall), the individual 
segments vary in thickness; the mucous membrane of the interstitial 
portion and of the part situated near the uterus is wholly, or almost 
wholly, devoid of folds; the transverse section usually appears stellate. 
The epithelium is cylindrical, forms a single layer, and 
resembles the uterine epithelium; in recent preparations cilia are 
seen. — In the section 
near the abdominal ori- 
fice (fimbrife) the mu- 
cous membrane exhib- 
its well developed folds, 
and in cross-section the 
picture appears al- 
most villous or gland- 
ular, suggesting the 
picture of malignant ^j^ ^ 

adenoma of the uter- 
ine body (Fig. 74, a) 
(see below). The nor- 
mal tube contains no 
glands, although the 
microscopic picture ap- 
pears glandular. But, 
as in the case of all 
surfaces covered with 
cylindrical epithelium, pathologic processes may lead to pro- 
liferation of the epithelium and the formation of depressions or glands 
(see below). Generally speaking, the Fallopian tube does not alter during 
menstruation or in pregnancy (except in tubal pregnancy, see below); 
cases have been described, however, in which the entire tube took 
part in menstruation, as well as in the changes incident to pregnancy. 

The Fallopian tube in children and in new-born infants 
does not differ in its outward shape from that of adults, but is, of course, 
smaller in size; but owing to the greater development of the circular mus- 
cle bundles and the slight development of the longitudinal bundles, 
the Fallopian tube is more tortuous than during sexual maturity. — 

Preparations of Fallopian tubes frequently exhibit the remains of 
parovarian ducts in the mesosalpinx, as epithelial ducts with cylin- 
drical epithelium surrounded by well-developed, circular muscle layers. 






S^ 



Fig. 74. — Transverse Sections of the Fallopian Tubes, a. 
At the abdominal orifice, rich folds of mucous membrane. 6. In the 
middle of the tube the folds of mucous membrane are not so well 
developed, c. Tube within the uterus (interstitial portion), a simple 
canal. At a the mesosalpinx contains parovarian tubules. (Original.) 



124 GYNECOLOGICAL DL\GNOSIS 



Diagnosis of Normal Pregnancy. 

Although the diagnosis of pregnancy does not strictly belong to 
gynecological diagnosis, it must nevertheless be discussed in this con- 
nection, partly because it is made in exactly the same way as the diag- 
nosis of. gynecological diseases, particularly during the first months of 
pregnancy, i.e., by combined examination, and partly because the 
findings in a number of gynecological affections are so similar to the 
conditions found in pregnancy that the latter always plays a most 
important part in the differential diagnosis. The diagnosis of normal 
pregnancy is particularly important for the physician because it is a 
diagnosis that can be confirmed better than any other. "Nunquam 
fere magis periclitatur fama medici, quam ubi agitur de graviditate 
determinanda, " says van Swieten in speaking of the annoyances that 
may accrue to the physician from a mistaken diagnosis of pregnancy. 
It is therefore the part of wisdom on the part of the physician not to 
announce or exclude this condition, which brings such a momentous 
change into a woman's life, until the diagnosis is established beyond 
the possibility of a mistake. If there is any doubt, it is wiser to wait a 
month longer. A woman does not usually expect a diagnosis of preg- 
nancy before the third or fourth month, and at this period the diagnosis 
can usually be made with certainty. Before that date it must always 
be dubious in the hands of any but a very experienced practitioner. 

The diagnosis of pregnancy is absolutely certain when the presence 
of a child within the uterus can be demonstrated. The first signs of 
this, however, cannot be positively determined until about the middle 
of pregnancy, so that they are available only for the second half; during 
the first four or five months the diagnosis must be based solely on 
changes in the maternal genitalia, and for this reason there is a funda- 
mental difference between the diagnosis in the first and the diagnosis 
in the second half of gestation. 

The diagnosis of pregnancy during the first half of gestation is 
based on the demonstration of changes that develop in the genitalia 
under the influence of an increased blood supply and the growth of the 
ovum within the uterus, which begins at the time of impregnation, and 
consists in changes that take place in the blood- and lymph-vessels as 
well as in hypertrophic conditions of the mucous membranes and the 
uterine muscle. The uterus itself is affected by the growing ovum, 
w^hich is attached in the neighborhood of the tubal orifices and separates 
the two walls of the uterus, but at first does not grow at the same rate 



SPECIAL DIAGNOSIS 125 

as the uterus itself. The periphery of the ovum does not everywhere 
reach the uterine wall until the end of the third month, when the decidua 
reflexa joins the decidua vera. From this time on the viterus and ovum 
grow pari jmssu and the union of the two fetal membranes may take 
place at any time between the fifth and sixth months. 

The diagnosis of pregnancy must, under all 
circumstances, be based exclusively on the objective 
examination. 

The following changes are utilized in making the diagnosis: 

The introitus, after a few weeks, frequently shows a slight bluish 
discoloration of the mucous membrane of both vaginal walls, forming 
at the hymen a sharp contrast with the normal color of the mucous 
membrane of the vestibulum. The bluish discoloration is changes at 

most marked at the fold surrounding the urethral meatus ^^^ introitus. 
and on each side, where it merges with the lateral wall of the vagina. 
The discoloration is a matter of individuality and may be absent even 
when the fetus is living, particularly in primiparse, while in multiparse 
it is, generally speaking, more distinct. During the later months the 
color increases in intensity. A marked dilatation of the veins is super- 
added, and the introitus presents a characteristic bluish-black appearance, 
so that a single glance suffices to establish the diagnosis. Not infre- 
quently a slight dilatation persists after parturition, so that in multiparse 
a slight bluish introitus may be seen even in the absence of a pregnancy. 

A bluish discoloration at the introitus does not belong to pregnancy 
exclusively, being observed also in the presence of large tumors of 
the uterus and ovaries, when they produce great vascularity in the 
neighborhood. 

Case 4. In an elderly person, with an ovarian tumor of the shape and consistency of a 
gravid uterus, the diagnosis was extremely difficult and for some time I considered pregnancy 
because the introitus was a dark blue, such as is usually seen in the last montlis of pregnancy. 

Bluish discoloration at the introitus of the vagina is also occasionally 
observed in diseases associated with circulatory disturbances in the 
abdominal veins (cirrhosis of the liver, cardiac and pulmonary diseases). 

Similar, although less pronounced, changes are seen in the mucous 
membrane of the vagina. It appears livid, often of a reddish-blue 
and somewhat glistening, owing to its turgescence. The increased 
metabolism in the vaginal mucous membrane manifests changes in 

itself in an abundant desquamation of the squamous theVagma. 

epithelium, covering the surface with whitish shreds. The cervix 
also secretes somewhat more mucus than usual, so that the in- 
creased vaginal secretion is one of the regular phenomena of preg- 
nancy. The mucous membrane feels soft, loose, and velvety; 



126 GYNECOLOGICAL DIAGNOSIS 

pulsating vessels are not infrequently seen in the vaginal vault. But 
even these signs are subject to individual variations and may be com- 
pletely absent even in the presence of a living ovum; in multiparse 
they are usually more distinct. On the other hand, they may un- 
doubtedly occur in the absence of pregnancy, particularly with large 
tumors, especially myomata; in recent inflammations in the neighbor- 
hood of the vagina; in catarrh. A bluish discoloration of the vagina 
is also occasionally seen with an hematocele. 

The changes in the mucous membrane are most distinct and appear 

earliest in the vaginal portion of the cervix. The softening and 

the bluish discoloration of the mucous membrane are frequently the 

first signs of pregnancy. The mucous membrane is often 

Changes in . i i i • 

thePortio intensely blue, and erosions show a deep purple color; it 

feels very soft and boggy, while the subjacent cervical 
tissvie at first retains its normal consistency. During the late months, 
however, the latter also shares in the general softening. Old lacerations 
of the cervix become much more distinct during pregnancy because 
the cicatricial tissue forms a contrast to the softer surroundings. 
In primiparse the external os becomes rounder. Softening of the 
vaginal portion is not a positive sign of pregnancy, as it is also quite 
distinct in chronic fungous endometritis and metritis, and in recent 
inflammations in the neighborhood of the uterus. 

The most important changes produced by pregnancy are found 
in the uterus itself and are: an increase in size, and softening. The 
enlargement may be detected by a practised hand as early as the 
Enlargement of sccoud mouth; in the third month it can hardly escape 
the Uterus. -j.]^g notice of eveu a less experienced examiner. The 

earliest change of shape demonstrable in the gravid uterus consists in 
a slight enlargement of its transverse diameter, caused by the increase 
in the thickness of the lateral walls; but the increase in the diameter does 
not become distinct until the sagittal diameter also increases and the two 
walls are separated by the growing ovum. As long as the uterus is 
still in the pelvis, the enlargement is easily demon-strated; as it increases 
in size, however, and rises out of the pelvis, i.e., in the fourth and fifth 
months, the diagnosis of pregnancy becomes difficult because one 
cannot be certain that the distinctly palpable tumor is the uterus; 
for about this time the gravid uterus usually becomes greatly ante- 
flexed, and, as the vaginal portion is therefore situated posteriorly at 
the pelvic wall, it is often impossible to recognize with certainty where 
the cervix joins the uterine body, particularly if the uterine segment 
is very much softened (Fig. 75). Under these circumstances one is 
often tempted to mistake the gravid uterus for a tumor and to assume, 
by the direction of the vaginal portion, that the uterus is behind it in 



SPECIAL DIAGNOSIS 



127 



retroversion. It is often absolutely impossible to demonstrate the 
cervical angle through the anterior vaginal vault, and the connection 
between the cervix and the uterine body can be recognized with cer- 
tainty only by palpating upward along the lateral margin of the va'ginal 
portion of the cervix. 

The softening of the uterus is subject to wide individual varia- 
tion. The organ is sometimes so soft that it cannot be felt at all, or the 
outlines of its resistance can be differentiated from the intestines 




Fig. 75. — Gravid Uterus in the Fifth Month in Marked Anteflexion. P.-F. K- (Original.) 



Softening of 
the Uterus. 



only by the very lightest pressure. In such a case, if the entire uterus 
is grasped between the widespread fingers and the intra-uterine tension 
increased by uniform pressure in all directions, palpation 
becomes very much easier. On the other hand, soften- 
ing may be entirely absent in a normal pregnancy; in that case the 
vaginal portion and the vagina are, as a rule, less blue and less succulent. 
The slightest grade of softening of the uterus can be distinctly recog- 
nized in such cases by grasping the organ between both hands and 
making slight pressure. The slightest degree of elasticity, the merest 
suspicion of yielding (impressibility) indicates softening, whereas the 
non-gravid uterus is hard and unyielding. In primiparte and in the 




128 



GYNECOLOGICAL DIAGNOSIS 



presence of complications with mild grades of metritis, softening of the 
uterus is very slight. Not infrequently the gravid uterus may be felt 
in the midst of contraction; the organ feels hard and tense, but soon 
becomes soft under the fingers. This change in consistency is 
the most positive sign of pregnancy. Sometimes a gravid 
uterus that shows but little softening presents irregularities in its outline, 
ridges and projections, caused by partial overlapping of the muscu- 
lature. These irregularities sometimes have the shape of interstitial 
myomata, for which they may be mistaken, or they may simulate fetal 
parts felt through the wall. As palpation is continued, however, they 
disappear or change their shape. When these partial contractions 
form in a circle at the cornu of the uterus, portions of the organ may 

be constricted off from the main part and 
simulate cystic tumors of the adnexse. 
As a rule, these contractions are transi- 
tory and the picture soon undergoes a 
complete change. 

The softening of the uterus is most 
distinct in the lower uterine segment 
before it is occupied by the ovum. 
While the upper portion of the uterus, 
on account of the presence of the ovum, 
becomes more tense, and the cervix, 
owing to the slight degree of succulence, 
forms a sharp contrast with it, the inter- 
mediate portion of the uterus becomes 
so thin and pliable that it often escapes 
the sense of touch altogether because the 
two softened walls of the uterus are in contact. If the uterus is in 
the normal position, and the internal hand is introduced into the anterior 
vaginal vault while the external hand is placed on the posterior surface 
of the uterus, immediately above the internal os, the two hands 
apparently touch each other (Fig. 76). 




Fig. 76. — Position or the Hands in 
Examining for Hegak's Sign of Preg- 
nancy (after Hegar). 



Note. Tliis obliteration of the lower uterine segment can also be demonstrated 
during the later months when it is completely occupied by the ovum, because the movable 
portion of the ovum, the amniotic fluid, yields to the pressure of the finger. The coinci- 
dent distention of the body of the uterus, although it can barely be demonstrated by palpa- 
tion, is in proportion to the compression of the lower uterine segment. In this sense, therefore, 
the so-called Hegar's sign is the earliest sign of pregnancy directly dependent on the ovum, 
and is exceedingly important in the diagnosis of early pregnancy. 

The greater the softening of the uterus as a whole, the more dis- 
tinct will be the obliteration of the lower uterine segment; but it is 
present also, as a rule, when softening of the entire organ is only 



SPECIAL DIAGNOSIS 129 

moderate. In my opinion the sign is not so important in the 
diagnosis of a normal pregnancy as it is in cases which present special 
difficulties, particularly when there is an absence of softening. I have 
found it exceedingly useful in the diagnosis of pregnancy with a dead 
fetus, and in retention after abortion; in very early pregnancy also it 
is at this point that the first signs of softening are most frequently found. 
For the practitioner a familiarity with this peculiar characteristic of the 
lower uterine segment is particularly important because it is the source 
of the great difficulties that are occasionally encountered in the diag- 
nosis of pregnancy, such, for example, as the already mentioned ante- 
flexion of the gravid uterus and the difficulty of distinguishing between 
normal and extra-uterine pregnancy, which is by no means rare, 
particularly when the body of the uterus is lateral or posterior to 
the ectopic product. 

The suspicion of pregnancy may be aroused by the presence of an 
irregular bulging of a certain portion of the body of the uterus in con- 
nection with softening. These prominences are produced by excessive 
growth of that portion of the uterus which gives attach- Lo^ai Bulging 
ment to the ovum. They are most readily recognized of the uterus, 
when they are situated in one of the cornua. The corresponding 
cornu then appears prominent and dilated, while the other retains its 
normal shape. In connection with this asymmetry one occasionally 
feels delicate furrows running in a sagittal direction between the two 
different sections of the uterus. Softening and compressibility of the 
prominent portions are also necessary for a diagnosis of pregnancy, 
because the same changes in the shape of the uterus may be produced 
by a myoma. 

The certainty of a diagnosis of pregnancy is proportionate to the 
number of the above mentioned signs that can be demonstrated. The 
examiner should not content himself with one sign, but should examine 
all the organs that have been mentioned, attaching the greatest impor- 
tance to the changes in the uterus. 

The diagnosis of pregnancy during the second half is based on 
demonstration of the fetus. 

The earliest fetal sign is fetal movement, which may often 
be demonstrated at the end of the fourth month with the stethoscope, 
as a soft scratching or crackling, scraping sound; or even ^etai 

as a slight blow, particularly after the uterus has been Movements. 
forcibly compressed a few times. During the later months the pal- 
pable and visible movements of the feet and the short, vigorous blows 
of the trunk constitute a positive fetal sign. 

The fetal heart sounds can occasionally be heard by patient 
and attentive auscultation toward the end of the fourth month. As 



130 GYNECOLOGICAL DIAGNOSIS 

a rule, the degree of certainty necessary for a diagnosis can be obtained 
onlj^ at the end of the fifth month, or about the middle of pregnancy. 
Fetal Heart -"^s, ow'iug to the constant change in the position of the 
Sounds. fetus, the position of the heart sounds is variable, the entire 

surface of the uterus must be explored with the stethoscope. The 
sound is double, very low, and the rate is about 140 to 160 per minute. 
The sounds increase in loudness with the progress of pregnancy, 
and their position, corresponding to that of the fetus, also becomes 
more cohstant. 

The conditions necessary for successfully palpating the fetal 

parts are not present before the middle of pregnane}^; previous to 

that time they are surrounded by the amniotic fluid, and lie deep within 

the uterus, which is still hard and incompressible; but 

Fetal Part^ 

about this time the fetal head can occasionally be felt 
through the vagina, if it happens to be in apposition with the anterior 
wall and does not escape from the palpating fingers too quickly. By the 
sixth and seventh month the fetal parts have become quite hard, al- 
though they are still very movable, and can be demonstrated by external 
palpation; and as time goes on, the entire fetus becomes gradually more 
distinct so that all of its parts can be recognized. (For the methods to 
be employed for this purpose the reader is referred to works on 
obstetrical diagnosis.) 

Certain changes in the breasts develop as early as the first 
month of pregnancy. They consist in swelling and increased activity 
of the glands, which become hard and on pressure exude colostrum. 
Changes in -^^ the Same time Montgomery's glands, i.e., the sebaceous 

the Breasts. glands lu the areola, become enlarged, and glistening blue 
subcutaneous veins make their appearance. These changes produce a 
feeling of tension and pricking in the breasts, which early attract the 
pregnant woman's attention; in nulliparous women this sign is more 
important than in multiparte. Its diagnostic value is, however, ma- 
terially diminished by the fact that it is also observed quite frequent!}^ 
in cases of large myomata and ovarian tumors, and occasionally during 
menstruation. 

The history is of minor value in the diagnosis of pregnancy as 
compared with the objective examination; it should be used as a sup- 
port to the diagnosis arrived at by the visible signs, but should never 
form the foundation of the diagnosis. The only symptom 
of value in the diagnosis is the cessation of menstru- 
ation. This sign is of such tremendous importance in the eyes of the 
laity that every woman who has ever had sexual intercourse at once 
suspects pregnancy if she misses her periods. For a physician this 
method of making a diagnosis is wrong. If, however, a woman who ha& 



SPECIAL DIAGNOSIS 131 

always been absolutely regular in her menstruation suddenly misses 
a period without any previous gradual diminution in the flow, or general 
or local symptoms of indisposition, it is probable that she is pregnant; 
but the diagnosis can never be positive because even in perfect health 
the woman's menstruation may be delayed weeks or months as the 
result of some psychic impression, acute circulatory disturbance, over- 
exertion, and the like; while local, and particularly general diseases 
are a still more frequent cause of amenorrhea. For determining 
the date of the beginning of pregnancy, the sign is even less reli- 
able, because a woman may become pregnant during a period of 
amenorrhea due to other causes, such as lactation, so that the preg- 
nancy may be much more recent than the period of amenorrhea would 
indicate. The value of the sign is also restricted by the fact that a woman 
may menstruate during pregnancy. A menstrual hemorrhage from the 
endometrium may continue for a few months, or very rarely until the 
end of pregnancy, although to be sure, the bleeding differs from a normal 
menstruation by its duration and the pale and watery appearance of 
the blood. On the other hand, hemorrhages due to disease of the uterus 
or fetal membranes are quite frequent, and as such hemorrhages are 
usually described by women as "periods," the patient's statement that 
the menstruation has not ceased may mislead the physician. By a 
careful interrogation concerning the type and character of the bleeding 
the mystery may be cleared up. 

The symptoms of nausea and frequent vomiting have a 
certain diagnostic value, although these symptoms are also complained 
of by otherwise healthy women, particularly in connection with amen- 
orrhea. A patient's statements that she feels fetal movements must 
be accepted with great caution, because intestinal movements, pulsa- 
tion of arteries, the movements of a tumor and the like, are frequently 
mistaken for this phenomenon. 

The practitioner who depends too much on a patient's statements, 
or attaches more importance to them than to the results of objective 
examination, cannot hope to escape errors in diagnosis; but he who 
assigns them their true place will always be glad to find in them the 
desired confirmation of a diagnosis based on objective signs. 

Differential Diagnosis. — The differential diagnosis covers a very 
wide field, since every variety of abdominal tumor may be, and in 
fact has been, mistaken for pregnancy. As pregnancy is the most 
frequent cause of the development of an abdominal tumor, Differential 

we advise one who is not an expert diagnostician always Diagnosis, 

to think of pregnancy in diagnosing such a tumor, and to include preg- 
nancy in his differential diagnosis. By so doing he will not run so much 
danger of failing to recognize an existing pregnancy. 



132 GYNECOLOGICAL DL\GNOSIS 

Differential diagnosis plays a more important part, and encounters 
many more difficulties during the first half of pregnancy because 
at this time positive fetal signs are as a rule absent, and the diagnosis 
must be based solely on the shape and consistency of the uterus. The 
following conditions must be considered: 

Chronic metritis may be mistaken for pregnancy because it 
also gives rise to enlargement of the uterus and, especially in recent 
cases, to a certain degree of softening, particularly as the vaginal por- 
tion may appear succulent and of a bluish color. The mistake, however, 
is likely to arise only during the first two or three months, as inflam- 
matory swelling rarely causes enlargement of the uterus. In chronic 
metritis the uterus is more flat and not so much thickened, non-elastic, 
and resistant to the pressure of the fingers. The inflammatory thick- 
ening also involves the cervix and the lower uterine segment, so that 
Hegar's sign is absent. The vagina and introitus present no alterations. 
In doubtful cases the only safe course is to observe the further growth 
of the uterus, and it is always best to wait at least four weeks, because 
slight differences in size cannot be detected by palpation. The diagnosis 
will frequently have to be confirmed by the history, showing that 
menstruation continues to be normal. 

Hematometra plays an important role in the differential 
diagnosis among physicians, apparently because it is also associated 
with amenorrhea. In actual practice the condition, on account of its 
great rarity, hardly needs to be considered. The enlargement of the 
uterus in hematometra produces a uniform, spherical shape, whereas 
the gravid uterus is broader through the body. The cervix frequently 
takes part in the distention by the retained blood, becomes balloon- 
shaped and merges with the uterine body. The chief difference in the 
two conditions, however, is found in the consistency. In hematometra 
the enlargement of the uterus is due entirely to its contents, and it is 
therefore tense and distended like a balloon; never soft and dough3^ It 
is only in those rare cases in which part of the retained blood is absorbed 
that a soft consistency may be produced and simulate that of preg- 
nancy. If the occlusion at the cervix or vagina which has produced 
the hematometra can be demonstrated, the diagnosis is assured. The 
history may aid the diagnosis, inasmuch as the development of hema- 
tometra requires a much longer period of amenorrhea than is necessary 
to produce the enlargement of pregnancy. 

For the differential diagnosis from myoma the reader is referred to 
the chapter on that subject. For extra-uterine pregnancy, see page 143. 

During the second half of pregnancy diagnostic errors 
arc less frequent because at least one of the fetal signs is usually 
available; but as the heart sounds are often overlooked, or cannot be 



SPECIAL DIAGNOSIS 133 

found, and the fetal parts are not infrequently mistaken for something 
else, the literature of diagnostic mistakes is quite large. The difficul- 
ties are increased when the fetus is dead, the heart sounds are no longer 
present, and the fetal parts can no longer be distinctly palpated. It is 
needless to say that at this period the conditions to be considered in 
the differential diagnosis are large tumors, and other changes must 
therefore be taken into account. 

Quite often a woman supposes herself pregnant because her abdo- 
men increases in size owing to an increase of the panniculus adiposus, 
particularly if at the same time the menstruation ceases, as, for example, 
at the beginning of the menopause. Pronounced meteorism and ascites 
may also arouse the suspicion of pregnancy. Careful percussion and 
palpation and finding a uterus of normal size will suffice to clear up the 
diagnosis. 

Greater difficulties are encountered in the differential diagnosis from 
large myoma, ovarian tumors, and advanced extra-uterine pregnancy. 

In this connection I repeat that there is no better way to clear up 
a doubtful case of pregnancy than to observe the growth of the uterus. 
My experience with the mistakes of practitioners teaches me that 
during the first half, pregnancy is more frequently overlooked, and the 
existing enlargement of the uterus mistaken for a myoma or an inflam- 
matory swelling; while in the second half, neoplasms are more often 
erroneously diagnosed as pregnancies, either because the physician has 
been misled by the patient's suspicions or because pregnancy appears 
to him the most probable diagnosis. 



134 GYNECOLOGICAL DIAGNOSIS 



Diagnosis of the Disturbances of Pregnancy. 

Of equal importance as normal pregnancy to the gynecologic 
diagnostician are the many disturbances which occur during the preg- 
nant state and which are characterized by definite gynecologic palpa- 
tory findings, and often need to be taken into consideration in the 
differential diagnosis of cases properly belonging to gynecology. They 
shall therefore receive attention in this place. 

Diagnosis of Pregnancy with a Dead Fetus. 

If the fetus dies during pregnancy it may be retained in the uterus 
for weeks and months, even beyond the term of normal gestation (missed 
abortion and missed labor). Cessation of the fetal movements and of 
increase in the size of the abdomen in the presence of an almost certain 
pregnancy, persistent hemorrhages, or disturbances of the general 
health almost always cause the patient to consult a physician, so that 
the diagnosis of this condition is of great practical importance. 

The diagnosis is easy in proportion as the pregnancy is advanced; 
during the last months particularly it presents no difficulties whatever 
if, on repeated examination, no heart-sounds are heard or fetal move- 
ments can be demonstrated, and their absence cannot be 

Diagnosis in i • i i i i • i 

the Second Half explamed by hydrammon; or the woman states that the 

of PrG2!ns.iicv. 

fetal movements, which she had always felt quite dis- 
tinctly, suddenly disappeared and the abdomen ceased to grow. If 
the fetus is retained several months, the fetal parts and even the head 
become so soft that they can no longer be recognized with certainty 
through the uterine wall by palpation. As, in addition, fetal sounds 
and fetal movements, in fact all the fetal signs of pregnancy are absent, 
the diagnosis of pregnancy may be doubtful, and at this period of 
gestation it can be made only by changes in the genitalia, especially 
by the softening of the enlarged uterus. 

During the first half of pregnancy fetal death can be recognized 
only by certain definite maternal signs, chiefly a disappearance of the 
softening and discoloration of the mucous membrane. The introitus 

and the vagina present practically no bluish discoloration 

Diagnosis in . t i ,i i i n mi 

the First Half at all aiici sometimcs are slightij' reddened, ihere is no 
softening of the vagina, or the softening is exceedingly 
slight for the corresponding period of gestation; and the disappearance 
of the signs of pregnancy is even more conspicuous in the vaginal por- 
tion. The uterus no longer feels soft and doughy; it becomes harder 



SPECIAL DIAGNOSIS 135 

and at the most its walls retain a certain degree of indentability which 
is preserved more at the lower uterine segment than elsewhere. In 
a few cases the elastic softening, which characterizes the gravid uterus 
with a living fetus, is replaced by distinct fluctuation. The greater 
the interval that has elapsed since the death of the fetus, the more com- 
plete will be the disappearance of all signs of pregnancy. As the soft- 
ening of the uterus even with a living fetus varies greatly in individual 
cases, its absence cannot be taken as a positive sign of fetal death; 
there must be absolute proof that softening had been present and that 
it has subsided. A most reliable sign is the arrest in the growth of the 
uterus; and if the fetus has been retained for some time, a moderate 
diminution in size, due to absorption of the amniotic fluid, mummifica- 
tion of the fetus, and involution of the uterine wall, is noticed. The 
arrest in the growth of the uterus produces a discrepancy between the 
size of the organ and the calculated period of pregnancy which, of course, 
increases in proportion to the length of time that the ovum is retained. 
This apparently very reliable sign unfortunately loses some of its 
diagnostic value by the fact that women not infrequently conceive 
during a protracted period of amenorrhea, for example, during lacta- 
tion, or after convalescence from typhoid fever. In this way a discrep- 
ancy arises between the duration of amenorrhea and the size of the 
uterus, a discrepancy which, however, does not justify a diagnosis of 
fetal death; the more pronounced this discrepancy, the more probable 
it is that conception has taken place during amenorrhea. Personal 
observation of the arrest in the growth of the uterus is the only abso- 
lutely certain method of arriving at a diagnosis; this, however, necessi- 
tates a period of observation of at least several weeks. It is, therefore, 
a good rule never to make a diagnosis of fetal death during the first 
half of pregnancy after the first examination, and to withhold one's 
opinion until further enlargement of the uterus has been excluded by 
personal observation at a second examination, made some time after 
the first. I have occasionally seen mistakes occur in estimating the 
size of the uterus because it was palpated during a labor pain. 

The method of making a diagnosis of fetal death is illustrated by 
the following case: 



^fa 



P 



Case 5. Mrs. R. presented herself on the 11th of December, 1895, because she no 
longer noticed any increase in the size of the abdomen, although she had been supposed to 
be pregnant. The last menstruation occurred about the middle of June. In October she says 
she passed blood and mucus for a few days, accompanied by labor pains. Examination 
revealed a very much softened vagina and vaginal portion, and a normally situated uterus 
about the size of a fist, round and of soft consistency, with distinct softening of the lower 
uterine segment. Pregnancy since June with a living fetus was excluded on account of the 
small size of the uterus. It seemed to me improbable, on account of the marked softening 
of the genitalia, that the fetus had been expelled unwittingly during menorrhagia and that 
the placenta had been retained for almost two months. The diagnosis lay between a preg- 



136 GYNECOLOGICAL DIAGNOSIS 

nancy with a dead fetus dating from June, or a pregnancy with a hving fetus of about three 
months' duration, which therefore must have begun during a period of amenorrhea. On 
account of the distinct softening I would have adopted the latter view at once, particularly 
as the patient did not complain of a single symptom, had it not been for the statement of a 
very experienced gynecologist who, toward the end of August, had definitely diagnosed a 
pregnancy of about two or three months' duration. For this reason pregnancy with a dead 
fetus was the most probable diagnosis, in spite of the remarkable softening of the tissues, 
and I decided to wait four or five weeks before giving a positive diagnosis. On the 13th of 
January, 1896, the patient again came to see me. The softening had diminished consider- 
ably and had disappeared completely from the vaginal portion. The uterus had diminished 
somewhat hi size and there was distinct fluctuation. I now made a positive diagnosis of 
pregnancy with a dead fetus. There were still no symptoms. On the 30th of January, 1896, 
the ovum was expelled spontaneously. It consisted of a greatly mummified fetus, about 
14 cm. in length, and the placenta. 

As compared with these positive signs the symptomatology is no 
longer of importance, although certain statements on the part of the 
patient may arouse the suspicion of fetal death. These are a bad taste 
in the mouth, loss of appetite, increasing lassitude, general 
FetfrDeat°! i^l health, the sensation of a foreign body rolling about in 
s°m toms ^^^^ abdomen, chilly feelings and the like. Some of these 

symptoms are complained of when the fetus is living, 
particularly if there have been long-continued hemorrhages. Hemor- 
rhage during pregnancy is by no means a sign of fetal death; it occurs 
much oftener with a living fetus, while, on the other hand, it may be 
absent when the child is viable. 

Diagnosis of Abortion. 

The first suspicion of abortion is usually aroused by hemorrhage 
recjuiring medical aid, either during an undoubted pregnancy or when 
pregnancy has not been suspected. The first question that must be 

answered in these cases is: 

Has an abortion taken place? The diagnosis of abortion is easier 
if it is known, either from previous examinations or from definite 
statements on the part of the patient, that pregnancy exists. In a 
Diagnosis from pregnant woman certain symptoms at once point to abor- 
the Symptoms, ^ion, particularly a certain kind of hemorrhage. Abundant 
hemorrhage, or the discharge of recent venous or arterial blood, is due 
to recent separation of the ovum during abortion; whereas the blood is 
brownish or brownish-yellow, or mixed with mucus, when there is endo- 
metritis or some disease of the ovum, and the blood has been retained for 
some time in the uterus. The diagnosis of abortion is still more probable 
when a pregnant woman has had labor pains. The feeble uterine con- 
tractions which accompany abortion during the early months are not 
always recognized by the woman as labor pains, especially if she is a 
primipara; but they reveal their true character to the physician by 
their rhythmical, "jerky" occurrence, the dragging pains in the sacrum, 



SPECIAL DL4GNOSIS 137 

abdomen, and intestines, the downward pressure on the bladder and 
rectum, and the hemorrhage, which completes the picture. It is true that 
even labor pains are not always a sign of immediately impending abortion, 
as they may be present for some time in certain disturbances, especially 
in endometritis, without interrupting pregnancy; when, however, they 
are associated with hemorrhage they usually usher in an abortion. 

By combined examination it can be determined positively whether 
an abortion is in progress. If, instead of the uniformly soft uterus, a 
distinct hardening of its walls is felt, it should be regarded as the 
objective proof of labor pains. During abortion the consist- 
ency of the uterus often becomes uniformly hard and the Based^on the 
tension of the walls is increased, so that it may appear ^aianges! 

harder than a non-pregnant organ, while at the same time 
differing decidedly from the soft gravid uterus. The changes in the 
cervix and in the ovum which are produced by the labor pains are the 
most valuable signs, but they do not include dilatation of the external 
OS and lower segment of the cervix, which are among the most 
frequent phenomena observed in multiparse. If, however, the upper 
portion of the cervix or even the internal os is dilated or admits 
a finger, it is a positive sign that labor pains are about to expel the 
ovum, or that the ovum has just been expelled. Dilatation of the cervix 
is the most reliable sign of abortion in pregnant women; the phenomenon 
may occasionally disappear temporarily, but abortion is nevertheless 
bound to occur sooner or later. If the finger is introduced into the 
uterus, the ovum is felt immediately above the internal os, or even 
occupying the cervix itself. 

The simplest way to make a diagnosis of abortion is by the fetal 
parts, whether they have been expelled spontaneously and delivered 
to the physician for examination, or are expelled during examination, 
or positively recognized as such within the uterus. A 

. . Diagnosis 

careful examination must be made of everything that is Based on the 
expelled from the uterus, as the findings of a minute portion 
of the ovum may suffice to establish an otherwise difficult diagnosis. 
(The anatomical examination of fetal parts will be discussed later.) 
It is needless to say that recognition of fetal parts is most difficult if 
the examiner is restricted to palpating them within the uterus. (For 
the findings within the uterus during the various stages of abortion, 
see page 141.) The remains of an abortion can always be distinguished 
from polypi and malignant disease not only by their peculiar shape and 
consistency, but chiefly by the fact that they are always easily separated 
from the uterine wall. The interpretation of the palpatory findings is 
more difficult, however, when the fetus is dead and has been retained 
for some time in the uterus, because the ova are round and hard and 



138 GYNECOLOGICAL DL\GNOSIS 

for that reason easily mistaken for submucous myomata or sarcomata. 
They differ from tliese, however, by the fact that they can easily be 
crushed, and particularly, as has been stated, by the ease with which 
they can be separated from the uterine wall. 

The diagnosis of abortion is much more difficult in the absence of 
positive proof of pregnancy. Under these circumstances, an attempt 
should first be made to establish this point, because it gives the correct 
interpretation of all the previously described symptoms and objective 
signs. Unfortunately, the diagnosis encounters great difficulties because 
with the beginning of abortion the softening of the vagina and vaginal 
portion becomes much less, particularly if hemorrhages have been present 
for some time; the uterus itself during abortion is considerably smaller 
on account of the persistent tension of the muscle and the labor pains, 
the characteristic softening also is absent. These difficulties in the way 
of a diagnosis of abortion are especially marked in the second month 
because, owing to the changes that have just been described, the uterus 
closely resembles a non-gravid organ, whereas during the third and 
fourth months it is considerably larger, and usually also somewhat 
softer than a non-gravid uterus. In these cases Hegar's sign is very 
valuable. The history is often of little use in these cases because regular 
and irregular hemorrhages during pregnancies that end in abortion must 
occur so early that the amenorrhea of pregnancy either cannot be 
demonstrated at all, or menstruation merely appears to have been 
delayed a few days beyond the normal period. Amenorrhea, neverthe- 
less, if positively demonstrated, is an important element in the diag- 
nosis. The diagnosis of abortion is not difficult if the cervix is patulous 
and the ovum can be felt. 

Once the diagnosis of abortion has been positively established, a 
second question must be answered because it is of prime importance in 
the treatment of the case. This question is: 

In what stage is the abortion ? Abortion begins with the first 

changes in the genitalia, which do not subside again, and ends with 

the expulsion of the last fetal part. As a rule, abortion is a protracted 

process and may extend over many weeks and months. 

Diagnosis of . . • i i i • 

the Stage of (The lougest abortion, m my own observation, lasted thirty- 
two weeks.) As the physician's aid may be demanded 
at any moment during this period, obviously, abortion in a great variety 
of stages is encountered. For practical purposes we distinguish three 
stages which, however, merge imperceptibly one into the other: 

1. Threatened abortion. 

2. Beginning abortion with intact ovum. 

3. Incomplete abortion (retention of fetal parts). 

4. Complete abortion. 



SPECIAL DIAGNOSIS 139 

The diagnosis of these conditions is made most easil}^ and with the 
least amount of danger to the patient by the fetal parts that have been 
expelled; hence the physician should first ask to see the discharged 
materials in every case of abortion and attempt to build up the ovum 
from the individual pieces in the same attitude which it occupied in 
the uterus. If all the parts are obtained, both fetal and maternal, 
abortion is complete, and no further examination of the patient is neces- 
sary; even if a few pieces of decidua are wanting, it is not necessary to 
explore the uterus for diagnostic purposes because their presence usually 
has no influence one way or another on the subsequent course of the 
case. All the fetal parts must, however, be accounted for before the 
physician ventures to form an opinion in regard to the stage of the 
abortion with which he is dealing. The patient's statements on this 
point are of no value whatever, because large portions of the ovum, or 
even the entire fetus, may be expelled unobserved during the third and 
fourtti months. For this reason it is not safe to base a diagnosis of 
threatened abortion or intact ovum on the patient's statement that no 
part of the ovum has been expelled. The information that "pieces 
have come away" may refer either to fetal parts or to pieces of coagu- 
lated blood, and a reliable diagnosis of abortion can rarely be made in 
this manner; nor is it possible to determine the stage of the abortion 
from the symptoms. 

Threatened abortion may be assumed if the hemorrhage is scanty, 
if it occurs at long intervals, if the fluid is largely mixed with mucus and 
contains very little fresh blood. An abundant flow of blood, particularly 
if the blood is fresh, whether arterial or venous, points to extensive 
separation of the ovum, and is practically a certain sign that abortion 
is in progress. If portions of the ovum are expelled, or the contents 
of the amniotic sac have been evacuated, the uterus contracts and the 
hemorrhage may cease, although large masses are still retained within 
the uterus. Renewed hemorrhages in such a case indicate that other 
masses have become detached. A profuse hemorrhage always points 
to retention, and as a rule the size of the retained portion is in proportion 
to the abundance of the hemorrhage. When abortion is complete, the 
hemorrhage is permanently arrested. The behavior of the labor pains 
also has some value for the diagnosis of the stage of the abortion. 
As a rule their severity is in proportion to the size of the fetus; 
hence if the uterine contractions are distinctly painful, the pres- 
ence of an intact ovum, or the retention of large masses, may be 
assumed. As soon as the uterus is empty, the labor pains cease; 
on the other hand, however, the absence of labor pains from time 
to time during the course of an abortion does not indicate that the 
process is completed. 



r 



140 GYNECOLOGICAL DIAGNOSIS 

It is not difficult to decide what stage of abortion one has to deal 

with if the cervix is patulous and admits one finger, as the condition 

of the ovum within the uterus can then be determined by palpation. 

. , If the ovum is still completely intact, it is felt in the second 

Diagnosis when 

the Cervix is mouth in the uterine cavity and vaay be recognized by its 

Dilated. i • i i i i • i 

spherical shape and polypoid attachment, whereas all the 
rest of the uterine wall is smooth; or the ovum may be descending, and 
in that case is also felt as a round body lying on the internal os, or in 
the cervix. In the third month the amniotic sac, usually quite flaccid, 
is felt; or fetal membranes and the fetal parts behind them; or, after 
evacuation of the amniotic fluid, the fetus itself maj^ readilj^ be 
recognized. In the fourth month these conditions are still more easy to 
interpret. Intact blood-moles are characterized by very thick fetal 
membranes and almost give the impression of placental tissue. The 
findings in a case oOncomplete abortion are quite different. During the 
second month the amniotic sac ruptures, or the ovum with its chorionic 
villi separates from the decidua; the remaining parts of the ovum col- 
lapse and form a polypoid body within the uterus or extend into the 
cervix, presenting a very irregular surface and friable consistency. 
If nothing but separated decidual tissue remains behind, it is found 
hanging within the uterus in loose shreds. Small particles of chorion 
and decidua reflexa produce merely a mortar-like roughness at the site 
of implantation. During the third and fourth months the placenta is 
often retained after expulsion of the fetus. A completely adherent 
placenta often escapes the sense of touch because the fetal surface, which 
presents toward the uterine cavity, is smooth like the uterine wall itself; 
but on more careful examination large vessels are occasionally felt on 
the surface of the placenta, or it is noticed that one uterine wall is 
thickened from the presence of a soft deposit; as soon as a part of the 
placenta separates, the diagnosis becomes easy. Pieces of the placenta 
take on the shape of the uterine cavity, which they completely fill, or else 
they protrude into the cervix. If abortion is complete, the cervix usually 
closes in a short time; within the uterine cavity the wall everywhere 
feels smooth, except for a slight roughness at the site of implantation. 
If the cervical canal is closed, as is often the case in protracted 
abortion, direct palpation of the ovum is impossible, as dilatation of 
the cervix for diagnostic purposes only is not permissible unless there 
is reason to suspect the presence of large masses that must 

Diagnosis when i t' • 

the Cervix bc rcmovccl at once. In such a case the diagnosis of the 

stage of the abortion must be made solely by the condition 
of the uterus itself. The shape and size of the uterus, and the degree of 
softening, are the only signs at our disposal for arriving at a diagnosis, 
which is often exceedingly difficult, so that even the most experienced 



SPECIAL DIAGNOSIS 141 

examiner is often mistaken in his diagnosis of the contents. The presence 
of an intact ovum may be surmised if the size of the viterus corresponds 
approximately to the calculated period of pregnancy, and the organ is 
soft to the touch. (It must be remembered, however, that these signs 
are not present when there is a dead, intact fetus.) Distinctly palpable 
labor pains are usually in favor of an intact ovum or the retention of 
large masses. If the fetus or part of the ovum has been expelled, the 
uterus contracts more firmly and loses its softness, particularly if there 
has been a severe or protracted hemorrhage. The softness and discolora- 
tion of the vaginal portion and the vagina also subside; hence, if the 
uterus is distinctly smaller than it ought to be for the duration of the 
pregnancy, and at the same time harder, retention may be assumed. 
It is obvious that a diagnosis between retention and an intact ovum 
must be very difficult in the second month, because the difference in 
the size before and after the expulsion of the ovum is so slight; and it 
is also obvious that the difficulties are practically insurmountable if the 
ovum is dead. The diagnosis becomes increasingly easier the later 
abortion occurs during pregnancy, because the uterus in that case is 
much smaller and becomes flattened after the fetus has been expelled; on 
the other hand, it also retains a considerable degree of softening for some 
time. Complete abortion may be assumed if the uterus has practically 
returned to its normal size, if it feels hard, and the bleeding has ceased. 
The diagnosis of retention alone should not satisfy the physician, 
and he should determine, if possible, the character of the retained 
portions; for it is of great importance in the treatment of abortion to 
know whether the uterus still contains the entire placenta 

Diagnosis of 

or only parts of the placenta, or the chorion, or whether Retained 

only decidual tissue with insignificant parts of the chorion 
are retained. This point also can only be decided by the size of the 
uterus and the degree of softening. If it is borne in mind that the size 
of the uterus during the early months is due more to the thickness 
of its walls than to its contents, it will be readily understood that owing 
to the individual thickness of the wall the uterus may seem to be very 
thick, although the retained masses are quite small; and, on the other 
hand, a uterus of normal size with thin walls may contain an ovum 
almost as large as a walnut. The diagnosis of the contents from the 
degree of softening is subject to the same difficulties, because the soften- 
ing depends on the vascularity, which differs in individual cases. 
It may be quite marked in the retention of decidual tissue and, 
on the other hand, altogether absent when large masses are retained, 
particularly if the woman has had hemorrhages for some time. It is 
extraordinarily difficult to decide whether decidual tissue or large por- 
tions of the fetus are retained in the uterine cavity, and mistakes are 



U 



142 GYNECOLOGICAL DIAGNOSIS 

quite as common as correct cliagnostications. One must be guided by 
the general principle that the larger and softer the uterus, the greater 
the probability that it contains fetal parts. During the third and fourth 
months the entire placenta is retained within the uterus in most cases. 
The uterus remains large and very soft, and shows a certain similarity 
to a gravid uterus, except that it is more flattened. If the placenta has 
been retained for some time, the uterus becomes smaller and harder, 
until finally, after months of retention, the increase in size may no longer 
be noticeable. 

For the general practitioner the diagnosis of the different stages of 

abortion resolves itself into the question whether there is threatened 

abortion, which in the particular case may be arrested, or whether the 

abortion is inevitable. This question is easily answered 

Can the . n i .p 

Abortion be if fetal parts are expelled; if any part of the ovum or no 
more than a piece of decidual tissue has escaped from the 
uterus, abortion is certain to occur. It may be expected also with a very 
great degree of probability if in the course of its progress the internal 
OS begins to dilate, and still more, if the amniotic sac enters the internal 
os; although the labor pains may subside temporarily, there is practically 
no hope that pregnancy will go on to its normal termination. Diag- 
nostic difficulties arise when the cervix is closed and the abortion is 
ushered in by hemorrhages and labor pains. In such a case one's judg- 
ment must be based on the character of the hemorrhage under labor 
pains. A brief hemorrhage, particularly if it follows a traumatism, 
permits a more favorable prognosis than a long-continued bleeding, 
even if the quantity lost is slight, because the latter points to disease 
of the fetal membranes or endometritis, which usually leads to abortion. 
Profuse hemorrhage almost always indicates inevitable abortion because 
it is due to separation of the ovum. Labor pains may occur in preg- 
nancy, and are quite likely to disappear again. But if they become more 
frequent and more painful, and particularly if they can be demonstrated 
objectively, there is great danger of abortion. Occasionally they may 
disappear with suitable treatment, but their cessation in many cases is 
merely temporary. 

If the diagnosis of a dead fetus has already been made, abortion is 
inevitable and no attempt should be made to prevent it. 

The uterine sound has but a limited application in the diagnosis 

of retention products, because soft, polypoid oval masses cannot be 

recognized with certainty with the sound, and further, if 

Diagnosis ° . -^ .' . ' 

with the the uterus contains large masses of tissue, the intro- 

duction of the sound is frequently productive of severe 
hemorrhage. For this reason the sound should not be employed when the 
uterus is large and soft. On the other hand, the sound is of great value 



SPECIAL DIAGNOSIS 143 

for the recognition of retained parts of decidua or small pieces of chorion, 
and for this reason it is most frequently employed for the diagnosis of 
abortion in the second month. If marked irregularities are discovered 
at the fundus, and the procedure is attended with increased hemorrhage, 
abortion may be suspected, even if the uterus is not enlarged or softened. 
Before the diagnosis of abortion is complete, it must be 

_ _ '^ Diagnosis of 

determined by examination whether the abortion is recent a Putrid 

~ . , , . . -r Abortion. 

or the parts are m a state of putrid decomjjosition. In 
cases of protracted abortion one must never neglect to take the temper- 
ature and investigate the odor for possible indications of decomposition. 
Finally, the diagnosis of abortion must be followed by an attempt, 
by means of a careful macroscopic and, if necessary, microscopic examina- 
tion of the fetus, placenta, and especially the fetal membranes, to deter- 
mine the causes of the abortion, especially if the history or the occurrence 
of repeated abortion points to some disease of the fetal membranes. 

Diagnosis of Extra=uterine Pregnancy. 

Definition. The term extra-uterine pregnancy is applied to 
every condition in which the impregnated ovum is implanted outside 
of the uterine cavity. Implantation may occur anywhere along the 
course of the tube, from the uterine orifice to the infundi- 

. . . Definition. 

bulum or even on the nmbria ovarica; or m the ovary, 
whether it be normal or in direct communication with a dilated tube. 
Primary implantation of the ovum on the peritoneum has not as yet 
been positively demonstrated. 

According to the site of implantation we accordingly 

,.. ., mi • • ••! 11/ -I- Classification. 

distinguish: lubo-uterine or interstitial; tubal (graviditas 

isthmica, ampullaris, fimbriae ovaricse); tubo-ovarian; ovarian; and 

abdominal pregnancy or gestation. 

Abdominal gestation is subdivided into primary, when the 
ovum is primarily implanted on the peritoneum; and secondary, 
when an ovum primarily implanted in the tube or ovary leaves these 
organs and continues its subsequent development on the peritoneum 
(Fig. 77). 

From the clinical standpoint we must include pregnancy in the 
rudimentary horn of the uterus among the varieties of extra-uterine or 
ectopic gestation, because it produces the same symptoms and usually 
cannot be differentiated clinically. 

The above subdivision of extra-uterine pregnancy is based on ana- 
tomical investigation and cannot be carried out clinically except in the 
rarest cases. Tubal pregnancy is by far the most frequent variety and 
must be regarded as the type of extra-uterine gestation. The diagnosis 
of this variety will therefore occupy our attention chiefly, and I shall 



144 



GYNECOLOGICAL DL\GNOSIS 



merely add as an appendix a few remarks about certain points which 
in favorable cases may render the diagnosis of the rarer varieties possible. 
The methods which we select for arriving at a diagnosis must be 
somewhat restricted in extra-uterine pregnancy, or at least must be 
employed with extreme caution, because the extra-uterine gestation 
sac is a structure that is very easily injured. Moderately severe pressure, 
or an attempt to displace it, may cause rupture and produce death from 
internal hemorrhage. It should therefore be an absolute rule to palpate 
with extreme caution and to employ very light pressure in every case in 
which there is a possibility of extra- uterine pregnancy; and especially 
under anesthesia, when the woman cannot defend herself by expressions 




Fig. 77. — Showing Implantation of Ovum in the Different Varieties of Pregnancy (after Bumm). 
1, uterine ; 2, tubal ; 3, interstitial pregnancy ; 4, implantation in tlie fimbriae ; 5, ovarian pregnancy. 

of pain, excessive pressure must be carefully avoided. Every patient 
with extra-uterine pregnancy must be kept under observation for signs 
of internal hemorrhage after the examination has been completed. The 
use of the sound should be avoided altogether, because the displacement 
of the uterus and adnexa which it necessitates may cause rupture of 
the gestation sac or necrosis of an existing hematocele. For the same 
reason digital exploration of the uterus and exploratory curettage are 
positively contraindicated. 

The diagnostic picture of extra-uterine pregnancy varies greatly, 
depending on the time when the patient is seen and the various ter- 
minations which result from interruption of the fetal development. 
Hence a subdivision based on these points is desirable, as it materially 
simplifies the diagnostic problem. As in the case of intra-uterine gesta- 



SPECIAL DIAGNOSIS 145 

tion, a division of the diagnosis into the two halves of pregnancy is 
useful, so also in extra-uterine pregnancy the same plan is followed 
because the principles which underlie the diagnosis are entirely distinct 
during these two periods. During the first four or five months the 
diagnosis is based on the changes seen in the maternal genitalia; 
during the second half of pregnancy, on the demonstration of the 
presence of a fetus. 

The diagnosis during the first half of extra=uterine pregnancy 
is based on the demonstration of changes which it produces in 
the maternal genitalia, i.e., on palpation of the gestation sac and the 
changes which occur in it as a result of the interrupted 
development of the ovum, and on the accompanying changes the Fh"? Half 
in the other genital organs, especially the uterus and vagina. °^ ^''pregnlncy! 
The great majority of cases of extra-uterine pregnancy are not 
seen by the physician until disturbances have occurred, and if the ovum 
continues to develop without symptoms, it is not discovered until the 
patient desires from the physician a diagnosis of pregnancy or some other 
disease; hence the physician very rarely has the opportunity of diag- 
nosing a uterine pregnancy in a natural process of development. 
Such a diagnosis would be a mere accident, while the diagnosis of an 
interrupted extra-uterine pregnancy is exceedingly common and of 
extraordinary importance. 

The diagnosis of symptomless extra-uterine pregnancy is for obvious 
reasons possible only during the first months because disturbances of 
various kinds usually appear early. It is based on the demonstration 
of a spherical or spindle-shaped swelling, which is sharply 
outlined, sometimes angulatecl, and forms a distinct con- Extra-uterine 
trast to the healthy, unchanged portion of the tube. The 
gestation-sac corresponds in size to that of the ovum because the thin 
wall of the tube does not increase the volume. It feels soft and doughy, 
but does not exhibit true tension or genuine fluctuation. It is not 
resilient but rather yielding, and differs in that respect from ovarian 
tumors and hydrosalpinx. The gestation-sac is quite movable 
unless it is attached to the surrounding structures by adhesions, in 
which case it soon loses its characteristic shape. In rare cases it is not 
pedunculated and grows between the two layers of the broad ligament. 
In such instances its connection with the tube is obscured, the shape 
is more spherical, and the wall becomes thicker because the broad liga- 
ment takes part in the hypertrophy incident to gestation. The uterus 
and vagina share in the palpatory findings, and also exhibit softening 
and hypertrophy (see page 153). 

Unusual symptoms in the course of extra-uterine pregnancy are 
usually the cause of an examination being desired. They may be from 

10 



146 GYNECOLOGICAL DIAGNOSIS 

peritoneal irritation, from rupture of the gestation-sac, or from threat- 
ened or actual expulsion of the ovum from the tube. In these cases 
medical aid is sought on account of sudden collapse, the sudden 

occurrence or periodical repetition of abdominal cramps, 
Extra-uterine persistcut hemorrhage, or on account of slight peritonitic 

signs or pressure symptoms. These symptoms therefore 
form the starting point of the diagnosis. The basic cause of these 
phenomena is the hemorrhage from the gestation-sac, which may, 
however, dead to a variety of different sequelae: 

1. Free internal hemorrhage. The general impression 
which these patients make on the physician is such as to leave no doubt 
in his mind that they are suffering from severe hemorrhage: apathy, 

pallor, small weak pulse in the severest cases, yawning and 
Hemorrhage into pcrsplration, at once suggest such a diagnosis. As external 
cavity'^°°^'°^' hemorrhage is absent, or very slight, the suspicion of internal 

bleeding is justified. Abdominal symptoms, vomiting, 
belching, and especially violent pain, at once direct attention to the 
abdomen. External examination reveals a slight distention and extreme 
sensitiveness to pressure, especially in the hypogastric region. If the 
loss of blood amounts to more than one or two litres, the free blood can 
usually be demonstrated by percussion in the lumbar region, and the 
resistance in this region is increased. Fluctuation is not present. While, 
therefore, the diagnosis of internal hemorrhage is usually positive, the 
source of the blood is not so easy to determine. Often dulness and 
increased resistance and sensitiveness to pressure in the hypogastric 
region direct attention to the genital organs. Internal examination, 
which must never be neglected in a woman in this condition, but must 
be performed with extreme caution on account of the danger of renewed 
hemorrhage, reveals a soft yielding resistance in Douglas' space, with 
slight anteposition of the uterus, or increased resistance in the region 
of the aclnexa. Still the diagnosis of ruptured extra-uterine pregnancy 
is only provisional, albeit extremely probable, because examination 
of the adnexa in this condition is impossible, or the changes are so 
slight that they cannot be demonstrated. In many cases the cessation 
of menstruation indicates the direction which the investigation should 
take; but as irregularities of menstruation are by no means rare, and 
as a tubal pregnancy may rupture before menstruation has ceased, this 
diagnostic aid is by no means always available. Nevertheless, if the 
existence of internal hemorrhage has been demonstrated, tubal preg- 
nancy is by far the most probable diagnosis. The difficulties are dimin- 
ished if the internal hemorrhage has not occurred unexpectedly but in 
the course of an extra-uterine pregnancy already under observation or 
has been preceded by pain on the diseased side. The patient's statement 



SPECIAL DIAGNOSIS 



147 



that she felt an acute pain — "as if something had given way" — simul- 
taneously with the beginning of the hemorrhage, may also help to 
suggest the correct diagnosis. 

2. Encapsulated hemorrhage. Rupture of a pregnant tube, 
or tubal abortion, more frequently leads to hemorrhage into the gesta- 
tion-sac, into Douglas' space, the region surrounding the Encapsulated 
tube, or the connective tissue of the broad ligament, than Hemorrhage. 
to free hemorrhage. As the blood coagulates, a distinctly palpable 
tumor is formed which, depending on its location, gives rise to a variety 
of physical signs. 

(a) If the hemorrhage takes place into the tube, either into the 
ovum or into the free cavity, palpation of the thus altered gestation- 




FiG. 78. — Left-sided Tubal Mole (without hemat.ocele-formation). P.-F. ^. (Original.) The 
uterine segment of the tube is free, also the abdominal; in the middle, between the two, is the hard, tortuous 
portion of the gravid tube distended with blood. 



sac is much more easy than in the case of an undisturbed pregnancy. 
The tube is distended by' the blood, and its shape and tortuosity 
can be readily recognized. The uterine portion of the tube (a) Hemorrhages 
is frequently free from blood, and its normal thickness and '"*° ^'''^ ^"'^''• 
soft consistency contrast sharply with the portion which is filled with 
blood (Fig. 78). The consistency of the tube is very hard and firm, 
and the tube is almost painless on pressure. Adhesions are frequently 
absent, hence these tubal tumors have a certain degree of mobility. 
The position of the tumor usually corresponds accurately to the normal 
position of the tube. 

(b) If the blood escapes rapidly in large quantities from the ruptured 
or aborting tube, it usually collects in Douglas' space, and the abdominal 
extremity of the tube is situated in its upper portion and there becomes 
encapsulated. A retro-uterine hematocele is formed, representing a 



148 



GYNECOLOGICAL DL\GNOSIS 



tumor which usually occupies the whole of Douglas' space and forces 
the posterior vaginal vault downward. The uterus is in anteposition 
and, if the mass of blood is very large, in an elevated position. The 
b) Retro-uterine ^Ize of the tumor depends on the quantity of the effused 
Hematocele. blood, and this iu turn determines the degree of displace- 
ment of the neighboring organs. In the case of excessive hemorrhages 
the blood also collects above the uterus, reaches to the anterior abdomi- 
nal wall, and produces large masses having extensive connections with 




i 



Fig. 79. — Retro-uterine Hematocele in Ruptured Left-sided Tubal Pregnancy. P.-F. H. 
(Original.) The hematoma extends beyond the uterus to the anterior abdominal wall, its irregular upper 
border being formed by coils of intestine which form its roof. 

the abdominal wall (Fig. 79). The rectum is displaced to the left and 
backward, and narrowed so that it forms a cleft, but never deflected 
in the form of a loop in cases of pure intraperitoneal hematocele. The 
roof of the hematocele is formed by intestinal coils which are matted 
together in various places and render the upper outline of the hematocele, 
particularly if it is recent, very irregular. In older hematomata the 
inflammatory phenomena subside, and the upper boundary may become 
sharply defined, as in the case of an ovarian tumor (Fig. 80). The 
connection of the hematoma with the neighboring organs is, of course, 
very intimate, because the blood comes in direct contact with these 



SPECIAL DIAGNOSIS 



149 



organs and undergoes coagulation. The firmest connection occurs at 
the posterior uterine wall; while the lateral wall of the pelvis, especially 
when the hematocele is small, is not always reached, so that the palpat- 
ing finger enters between it and the tumor. As a result, these tumors 
present a moderate degree of mobility with the uterus, and this may 
easily lead to error in the diagnosis. The consistency is an important 
factor in the diagnosis of an intraperitoneal efi^usion of blood. Recent 
hematoceles are usually soft and flabby, like flaccid cysts, but may 




Fig. 80. — Retrouterine Hematocele: About five months old, after ruptured tubal pregnancy. P.-F. 
Yi. (Original.) The upper outline of the hematocele is sharply defined, owing to encapsulation. 

become tense in a few hours; fluctuation is undoubtedly demonstrable 
in most cases. The blood soon coagulates and acquires a semisolid 
consistency, so that quite often differences between the fluid and more 
resistant parts may be recognized. As the inspissation of the blood 
continues and the fluid constituents are absorbed, the hard consistency 
of the zone of reaction becomes more and more distinct, and the char- 
acteristic feel of a hematocele is lost. The rapid transition from the 
cystic to a firm consistency is absolutely pathognomonic of hematocele. 
Only in exceptional cases the blood remains fluid for months and the 
consistency is that of a uniformly cystic tumor. The topography of 
the hematocele is more irregular when its position" is lateral, when part 



150 



GYNECOLOGICAL DIAGNOSIS 



of Douglas' space was previously obliterated, or hemorrhage into the 
lateral portion of Douglas' space has been followed by encapsulation. 
In this case the tumor occupies a lateral position at the posterior surface 
of the uterus, forces only part of Douglas' space downward and forward, 
and displaces the uterus to the other side. 

(c) If the blood escapes more slowly from the tube and in small 
quantities, or in successive hemorrhages, it coagulates at the fimbriae 
or at the site of rupture, and forms a peritubal hematocele (Fig. 81). 
(c) Peritubal The positiou of these blood tumors is extremely variable 
Hematocele. g^j^^ dcpcuds iu the main on the position of the fimbria?. 
As a rule they are to one side and behind the uterus, or they may extend 
below the level of the uterus and a little to one side; but quite frequently 




Fig. 81. — Distention of the Tube with Blood and Peritubal Hematocele in Tubal Preg- 
nancy. P.-F. Vi. (Original.) The uterine segment of the tube is free; next comes the part distended 
with blood, and the abdominal extremity is surrounded by a small effusion of blood. 

the tumor is found at the level of the pelvic inlet or even higher up. 
If the uterus is retroverted, the fimbria? occupy the anterior half of the 
pelvis, and a blood tumor is formed in front of the uterus. The size of a 
peritubal hematocele depends on the quantity of the effused blood. 
Its shape is at first always indistinct, quite irregular in outline, 
with outrunners in various directions, producing quite bizarre forms 
such as are rarely seen in other conditions. After it has existed for 
some time, however, and particularly if the peripheral layer undergoes 
organization, the tumor becomes more distinct and like an ovarian 
tumor. The attachment of the hematocele to the neighboring organs 
— uterus, rectum, or pelvic wall — is usually so intimate that it has a 
large surface of contact. For this reason, it is at first immovable, but 
may gradually develop a considerable coincident mobility with the 
uterus and tube, particularly if the fibrinous attachment with the pelvis 
disappears. The consistency of a peritubal hematocele is at first soft 



SPECIAL DIAGNOSIS 



151 



and yielding; later it becomes firm, but never decidedly hard. The 
rapid transition from a cystic to a firm consistency may often be 
observed in this variety. Occasionally the blood remains fluid for 
some time, and in this way an old hematocele with an organized cortical 
layer may form a tumor which, even macroscopically, is sometimes 
indistinguishable from an ovarian cyst. 

(cl) If the rupture of the tube is intraligamentary, the blood escapes 
between the two layers of the ligament and produces a so-called hema- 
toma of the broad ligament. If the hemorrhage is slight, a tumor is 
formed alongside of the uterus with a broad attachment to its lateral 
aspect, and during its subsequent growth crowds the uterus over to 
the opposite pelvic wall. If the hemorrhage is profuse, the blood 




Fig. 82. — Peritubal Hematocele and Hemorrhages into the Tube in Tubal Pregnancy. P.-F. 
(Original.) The uterine segment of the tube is but slightly thickened. It is joined by the portion of the 
tube which is distended with blood, and which on the outer side dips into a large hematocele that has formed 
around the fimbriated extremity. 

burrows a path for itself underneath the peritoneum of Douglas' space 
to the iliac bone, around the cervix to the opposite side of the pelvis, 
and may eventually descend between the vagina and the 

(d) Hematoma 

rectum, surrounding both organs as far down as the pen- of the Broad 
neum. Accordingly the shape of these tumors is exceed- 
ingly variable, although it is characterized by numerous outrunners, such 
as are seen in no other conditions except parametritic exudates. The 
consistency is usually hard because the blood infiltrates the connective 
tissue and rapidly coagulates. The connection with all the pelvic organs 
that lie in the path of the escaping blood is quite intimate. 

In most cases hemorrhages into the tube are combined with extra- 
tubal hemorrhages, giving rise to palpatory signs which make it possi- 
ble to separate the hard, tortuous tube, distended with blood, from the 
partially coagulated hematoma. In peritubal hematocele one is espe- 



152 GYNECOLOGICAL DIAGNOSIS 

cially apt to find, in the lateral and posterior portions of the pelvis, soft 
tumors presenting the above described peculiarities, and containing the 
extremity of the Fallopian tube distended with blood (Fig. 82). As the 
successive hemorrhages from the tube often occur at long intervals — 
weeks in some instances — different layers can sometimes be distinguished 
in the hematoma which correspond in hardness to the different ages of 
the successive hemorrhages. 

In the objective examination of all these tumors we first attempt 
to demoristrate the presence of a hematoma by the shape, position, 
consistency, and connection with neighboring organs. This being^ 
established, it becomes probable that the hematoma is due to a tubal 
pregnancy because other causes, if the hematocele is intraperitoneal, 
are extremely rare. In a certain number of cases the probability is 
increased if the tube distended with blood can be felt merging with the 
hematoma. Nevertheless, the number of cases in which we can recog- 
nize an extra-uterine pregnancy by the objective examination and the 
tumor alone, will never be very large. In the majority of cases, we may 
be able to demonstrate a hematoma, in others the tumor does not even 
show the peculiarities of a hematoma with absolute certainty, and the 
diagnosis of tubal pregnancy therefore remains uncertain, because in 
all cases of suspected tubal pregnancy the examination must be made 
with extreme caution in order to avoid rupturing the tumor. 

For this reason it is fortunate that we possess other objective signs 
of pregnancy which may assist in the correct interpretation of the 
otherwise doubtful abdominal tumor. These objective signs are: 

1. Signs of pregnancy in the genitalia (see page 
^giToT 127, et seq.). Softening of the vagina, vaginal portion, and 

ti^elseiiitaiia utcrus, and increase in the size of the uterus, do not, it is 
true, occur as regularly in tubal pregnancy as in intra- 
uterine gestation. When the interruption to pregnancy occurs early, 
or the fetus is dead, softening and increase in the size of the uterus are^ 
often entirely absent; on the other hand, if the fetus is living, these 
changes play an important role. As softening of the vaginal portion, 
bluish discoloration of the mucous membrane, and even pulsation of 
the vaginal arteries may also occur in all inflammatory conditions, 
the value of these signs must be judged with extreme caution during 
the first months of tubal pregnancy. 

2. The discharge of the decidua plays a much more 
important part in the diagnosis of tubal pregnancy. Under the con- 
gestion incident to pregnancy, the endometrium is converted into a 
decidua and is expelled in at least two-thirds of the cases, attended 
usually with severe pains resembling those of labor. The decidua 
is usually cast ofT as two membranes, which correspond to the two- 



SPECIAL DIAGNOSIS 



153 



walls of the uterus; rarely in single pieces. This debris is not often 
given to the physician for examination, and he is forced to rely on the 
statements of the patient, who, as a rule, gives an accurate description 
of a fleshy mass or masses. The decidua, which is usually discharged 
in the form of a closed sac, has a triangular shape with three openings, 
corresponding to the two orifices of the tube and to the internal os. 
The outer surface is rough; the inner surface is usually furrowed and 
occasionally contains areas infiltrated with blood (Fig. 83). The recog- 
nition of the decidua presents no difficulties, but the question whether 
the suspected membrane is a decidua from a tubal pregnancy, an abor- 
tion, or menstruation is not always so easy to answer. Abortion can 




Fig. 83. — Decidua in ExTRA-nxERiNE Pregnancy. (Original.) a. Cast of the uterus, the uterine 
surface presenting outward. 6. The decidua has been divided along the middle of the anterior wall and 
reflected on both sides. 



be positively excluded if neither half of the membrane contains an 
ovum or an opening for its escape; the menstrual decidua is thinner 
and is usually expelled in separate pieces; the decidua of tubal preg- 
nancy is the thickest of all. In many cases the question must be decided 
by the microscope. (See microscopic diagnosis of the membranes 
expelled from the uterus.) The discharge of decidua points to extra- 
uterine pregnancy if abortion and membranous dysmenorrhea can be 
excluded with certainty by the clinical course and the physical signs. 

Among 83 cases from my own clinic a positive history of the discharge of decidua was 
obtained in 36, and in 7 additional cases it occurred while the patients were in the wards. 

The fact that no decidua has been discharged is not against tubal 
pregnancy, because the membrane may remain behind in the uterus 
and by a process of involution be converted into normal endometrium; 



154 GYNECOLOGICAL DIAGNOSIS 

or its escape from the uterus may not be noticed. The discharge of the 
decidua, therefore, has only a positive value. The decidua is never 
discharged unless the tubal pregnancy is interrupted; it is always 
preceded by death of the fetus, rupture of the tube, tubal abortion, 
or hemorrhage into the tube. As, however, rupture and hemorrhage 
are not always followed by death of the fetus, discharge "of the decidua 
is by no means a positive sign that such an accident has occurred; 
but it always indicates a disturbance of some kind. The decidua is 
usually ^discharged a few hours or days after the beginning of the 
disturbance and the process is attended with protracted hemorrhage. 

An attempt has been made to utilize the regular development of a 
decidua in extra-uterine pregnancy as a diagnostic factor. A number 
of authors propose that the uterine membrane be curetted out for the 
purpose of demonstrating the decidua by microscopic examination. 
Such a procedure, however, is not permissible, because it has not infre- 
quently led to rupture of the ectopic sac, or to septic infection of the 
hematoma, with a fatal termination. But the most potent argument 
against the procedure is found in its unreliability; for during the early 
stage, when the demonstration of a decidua would be a particularly 
useful diagnostic point, the membrane is not always fully developed; 
or it is present only in spots, and the curette cannot be depended upon 
to bring any of it away; or it may have been already discharged without 
the patient's knowledge. Besides, the interpretation of the microscopic 
picture may be rendered difficult by retrogressive processes, or by the 
similarity of decidual tissue to other changes in the mucous membrane. 

3. The increased development and activity of the mammary 
glands which accompany pregnancy occasionally point to a diag- 
changesin uosis of extra-utcriue pregnancy, more, however, in the 

the Breasts. positive than in the negative sense. Even the presence 
of colostrum in the glands can be utilized only in the case of primi- 
gravidse, or when a considerable interval has elapsed since the last 
confinement, because the glands continue to exude secretion on pres- 
sure for a long time. As, however, a mammary secretion also occurs 
with inflammations and neoplasms of the internal genitalia, this sign 
must be utilized with great caution. After the death of the fetus a 
transformation of the colostrum into milk has occasionally been 
demonstrated. 

Even the above-mentioned changes incident to pregnancy do not 
always suffice to make it positive that an existing tumor is the product 
Diagnosis from of extra-utcriue pregnancy; quite often one is compelled 
the Symptoms. ^^ depend in part for the diagnosis on the history and 
symptomatology. The amenorrhea of pregnancy is almost regu- 
larly present, and entirely absent only in a very limited number of 



SPECIAL DIAGNOSIS 155 

cases. In most instances menstruation is at least delayed a few days 
before the first disturbances make their appearance. Rupture of the 
sac may, however, take place on or even before the day of the expected 
menstruation. Quite often menstruation occurs at the right time dur- 
ing extra-uterine pregnancy, but the quantity of blood discharged is 
diminished. Disturbances in the course of pregnancy, associated with 
hemorrhage, may be noted so early that they obscure the period of 
amenorrhea. For these reasons the patient's statements are not always 
to be depended upon; but any degree of amenorrhea, even if it lasts 
only a few days, may excite the suspicion of pregnancy. 

Among 79 cases from my clinic, amenorrhea was present in 67; in 3 cases the periods 
returned during pregnancy; in 9 amenorrhea was not observed because of disturbing hemor- 
rhages, which on 7 occasions occurred before the expected menstruation, and in 2 cases on 
the expected day of the flow. 

Subjective symptoms of pregnancy, such as nausea and 
vomiting, are less frequent in extra-uterine than in intra-uterine 
pregnancy, and for that reason have less diagnostic value. 

The history does not become typical until complications in the 
course of the extra-uterine pregnancy have made their appearance, 
such as tubal abortion, rupture of the ectopic sac, or death of the fetus. 
The symptoms consist in abdominal cramps of very abrupt onset, 
usually without any previous cause, but occasionally as the result of a 
traumatism of some kind (examination, lifting, dancing, and the like). 
These pains are described by the patient as lancinating pains, appear- 
ing suddenly in the abdomen or rectum, with syncope, vertigo, vomit- 
ing, and pallor. They are usually of short duration, but recur in a 
similar manner after a shorter or longer interval, several attacks being 
usually recognized in the course of the process. The pains are probably 
due to the hemorrhages that take place into the lumen of the tube or 
into the abdominal cavity. — The second symptom pointing to some 
disturbance in the course of extra-uterine pregnancy is external hemor- 
rhage, which may continue uninterruptedly for a long time, even sev- 
eral months. The hemorrhage is moderately severe; the blood is often 
mixed with mucus, rarely with pieces of tissue; and the hemorrhage 
occurs immediately after the above-described cramps, or sometimes 
after an initial attack. The decidua is usually discharged during the 
first days of the hemorrhage. As the occurrence of these symptoms 
lends considerable diagnostic importance to the history, I shall relate 
a few typical cases. 

Case 6. Mrs. S.; 41 years; married in her 21st year; seven confinements; no abortion; 
last confinement seven years ago. Never had any abdominal disease; last menstruation, 
December 24, 1893. On January 27, 1894, returning home after an evening of strenuous 
dancing, she was suddenly seized with severe tearing sensations in the rectum, vertigo, and 



156 GYNECOLOGICAL DIAGNOSIS 

nausea; no syncope. The pain lasted from one-quarter to one-half hour, but was not repeated. 
The abdominal cramp was attended with uterine hemorrhage, which has continued for seven 
weeks. No discharge of membrane has been observed. Findings: Peritubal hematocele with 
hemorrhages into the tube. 

Case 7. Miss N.; 19 years. First menstruation at the age of 14 years; regular 
every four weeks; always profuse and attended with abdominal pain. Last menstruation 
occurred on August 1, 1894; on September 1st, slight hemorrhage; on September 10, a more 
severe hemorrhage lasting five days, after which it ceased and returned after a bath; it has 
now been going on for six weeks. The hemorrhage came on after the bath, and at the 
same time she was seized with abdominal pain, cramps in the abdomen, syncope, 
vertigo, and nausea. After two weeks she had a second attack, exactly like the first. 
Discharge of the decidua was not noticed. Findings: Retro-uterine hematocele with 
hemorrhage into the tube. 

Case 8. Mrs. W., aged 24 years ; married four years ; had one full-term child 
three years ago; since then she has been ill, the last menstruation occurring on the 4th of 
December. About the middle of January she was seized with severe pain in the abdomen, 
lasting one-quarter of an hour and not attended with hemorrhage; in the beginning of Feb- 
ruary she had another severe abdominal cramp, lasting about the same time, which was 
repeated several times on the same day. The second abdominal cramp was attended with 
hemorrhage, which has so far lasted seven weeks. A week after the beginning of the hemor- 
rhage fleshy pieces were discharged without pain. The patient thought she was pregnant 
because of her abnormal appetite. Findings: Retro-uterine hematocele. 

The phj^sician's task is not complete when he has positively dem- 
onstrated the existence of extra-uterine pregnancy. Another question 
of at least equal importance remains to be answered, namely, the 
stage of development of the extra- uterine ovum. Its 
importance is due to the danger of hemorrhage which threatens the 
patient if the ovum continues to develop. So long as the fetus is alive, 
the mechanical conditions which tend to destroy the implantation- 
site of the ovum and those which cause arrosion of the tubal vessels 
continue and may unexpectedly precipitate the catastrophe of an 
internal hemorrhage. If, on the other hand, the connection between 
the ovum and the tube has been severed by its escape from that struc- 
ture, the danger of further bleeding is obviated and the retrogressive 
processes begin. As a rule, the destructive processes occurring at the 
site of implantation are arrested also if the ovum is dead, even though 
it is still attached to the uterine wall; occasionally, howevfer, the pe- 
ripheral portions of the ovum continue to invade the tissues at the site 
of implantation and thus severe hemorrhages may be produced. There- 
fore, so long as the ovum remains in the tube, it cannot be said that 
the danger of hemorrhage has been entirely removed. It is, therefore, 
important that the diagnostician shall advise immediate operation in 
cases in which a severe internal hemorrhage is probable, or at least 
within the realm of possibility. Such cases are: 

1. All cases with a living fetus. 

2. All cases in which the ovum is positively known to be still in 
the tube and the process has not been arrested (tubal mole). 



SPECIAL DIAGNOSIS 157 

That immediate operation is indicated in the first group of cases is generally conceded, 
and in most of the cases of the second group active interference is also required; on the other 
hand, in an extra-uterine pregnancy in which the ovum has been expelled beyond the possi- 
bility of a doubt, no operation is usually performed; and in cases in which the expulsion of 
the ovum is not definitely established, the expectant plan of treatment is followed. 

The diagnosis of a living fetus in the first half of preg- 
nancy can be made only by positively demonstrating the presence 
of a gestation-sac which is still undergoing development. Diagnosis of a 
In the absence of disturbances of any kind in the course L'vmg Fetus. 
of pregnancy, it may be assumed that the development is progressing 
if it has the above-described, uniform tension, and corresponds in size 
to that of the ovum. The uterus at the same time is usually somewhat 
enlarged and soft, and the vaginal portion and vagina also exhibit 
softening and bluish discoloration. 

A more difficult question to answer, after disturbances have made 
their appearance, is: which will be likely to interrupt the normal course 
of the pregnancy, and which are not necessarily followed by the death 
of the fetus? 

Interruption of the pregnancy by destruction of the ovum may be 
assumed to have taken place with the greatest degree of probability 
if a severe internal hemorrhage occurs. Large hematoceles, com- 
pletely filling the pelvis, also as a rule indicate death of the fetus, be- 
cause such severe hemorrhages are due to extensive separation of the 
ovum; there are, however, exceptions to the rule. Small hematoceles 
often occur coincident with the development of the sac. It is not safe, 
therefore, to draw the inference that the ovum is alive from the size of 
the ectopic sac and the fact that it corresponds to the period of gestation. 
On the other hand, it may appear too large because of hemorrhages 
into it, or a soft hematocele may be mistaken for an ectopic sac, and 
a living fetus diagnosticated if it happens to correspond in size to the 
duration of pregnancy. Even if continued growth of the gestation- 
sac has positively been established by observation, it is not absolute 
proof that, the ovum is still developing, because the growth may be 
due to hemorrhage. 

The signs of softening in the genitalia are too inconstant and vary 
too much in individual cases to be of any value; but if it can be posi- 
tively shown that such signs are subsiding, or if a previously observed 
pulsation in the vaginal arteries ceases, death of the fetus is extremely 
probable. The discharge of decidua is neither for nor against death of 
the fetus. Occasionally the occurrence of milk in the breasts, instead 
of previously demonstrated colostrum, may indicate interruption of 
the pregnancy and the beginning of the puerperal state. The pain 
which is characteristic of disturbances of development has no diagnostic 



158 GYNECOLOGICAL DL4GNOSIS 

value, because the hemorrhage into the tube does not necessarily cause 
death of the fetus. Similarly, protracted uterine hemorrhage may 
occur whether the fetus is dead or alive, although in the latter case 
such hemorrhage is, it is true, extremely rare. 

From my clinical material, I offer the following data as aids in the diagnosis of a living 
or a dead fetus : 

In 4 cases in which the fetus was unquestionably alive enlargement and softening of 
the uterus were found in 2; softening and discoloration of the vaginal uterine membrane in 
3; attacks of pain in 4; uterine hemorrhage (in one case lasting two and a half months) in 3. 

In 73 cases in which the fetus was luiquestionably dead, enlargement and softening of 
the uterus was found in 20; discoloration and softening of the vagina in 20; pulsation of 
the vaginal arteries in 8; discharge of decidua in 36; attacks of pain in 68; uterine hemor- 
rhages in 67 (in 63 the hemorrhage was protracted); increase in the size of the tumor in 3; 
diminution in the size of the tumor in 33. 

To illustrate the difficulties of making a diagnosis of a living fetus, 
I cite the following cases : 

Case 9. Mrs. S. Uterus enlarged and soft, displaced forward and to the left (sin- 
istro-anteposition) ; vagina somewhat softened, slightly bluish. On the right, beliind the 
uterus and at the level of the pelvic inlet, a tumor as large as the fist, merging with the tube; 
the abdominal half of the latter is thinned, wliile the uterine half appears to be approxi- 
mately normal. The consistency of the tumor is tense and cystic; somewhat harder at the 
inferior pole. Pulsation of the vaginal arteries. History: Last menstruation January, 1894. 
On March 26th a moderate hemorrhage occurred and this has continued imtil now with some 
interruptions. No discharge of decidua; no cramps; no attacks of syncope. The nausea 
still continues. The attending physician has noticed a uniform increase in the size of the 
tumor until lately. Laparotomy showed no living fetus, but a peritubal hematocele and the 
tube distended with blood emptying into it. 

Case 10. Mrs. H. Introitus slightly bluish ; vagina and vaginal portion somewhat 
soft (succulent); uterus large, not soft. To the left, and beliind the uterus a round timaor 
the size of the fist, with broad adhesions with the left lateral aspect and posterior surface of 
the uterus ; consistency distinctly fluctuating, with moderate tension ; no blood-clots can 
be found within the tumor. The history shows that the last menstruation occurred Decem- 
ber 18, 1893 ; since then a number of irregular hemorrhages of short duration ; several 
attacks of syncope, but no distinct cramps. A diagnosis of tubal pregnancy with living fetus 
is made because the size of the sac corresponds to the period of pregnancy ; because 
the tension is moderately elastic and the shape round ; because the length of the uterus is 
9 cm., and the vagina shows a marked degree of softening. Laparotomj' showed hematocele. 

Case 11. Mrs. H. Last menstruation in beginning of August, 1897; on August 30thj 
first attack of pain, which during the subsequent coiu-se of the disease was followed by eight 
more, the last occurring on the 30th of October. Examination on the 31st of October re- 
vealed a cystic tumor as large as the fist to the right, and beliind the somewhat enlarged 
uterus. The tumor was taken for a hematocele. A week later, however, I made a diagnosis 
of a living fetus because the tumor had increased somewhat in size, and particularly because 
the softening of the vaginal portion was distinctly increasing. Operation confirmed the 
diagnosis of a living fetus. 

Case 12. Mrs. A. Last menstruation in beginning of November, 1905, i.e., two and 
a half montlis ago. Since then complete amenorrhea. Beginning, middle, and end of Decem- 
ber, three attacks of severe abdominal pain resembling labor pains, wliich were chiefly local- 
ized on the right side. No attacks of syncope; no symptoms of anemia or peritonitis. 
Between the fii-st and the second attack the patient was entirely free from sjTnptoms; since 
the second attack she has had constantly slight pain in the right side and in the back, and 
sometimes nausea. During the past six weeks the breasts are said to have increased in size. 



SPECIAL DIAGNOSIS 159 

January 15, 1906, the following conditions were found: Vagina and vaginal portion some- 
what softened; uterus in sinistro-anteposition, of normal size and hard; to the right and 
between the uterus an approximately oval tumor, a little larger than a goose egg and of semi- 
sohd, but not distinctly fluctuating consistency; very slight mobility. The tumor fills the 
space between the uterus and the pelvic wall; the right tube, the uterine portion of which is 
somewhat tliickened, merges with the tumor at its upper aspect; pulsating vaginal arteries; 
the left adnexa cannot be palpated with certainty. Breasts contain no secretion. January 
20, a distinct enlargement is noted in the lower portion of the tumor; softening (succulence) 
of the vagina and vaginal portion becomes more distinct than before. A diagnosis of a living 
fetus was made because the tumor was growing, the succulence increasing, there were no 
uterine hemorrhages, and there had been no discharge of decidua. The diagnosis was con- 
firmed by laparotomy. 

There is no absolutely positive sign of life of the fetus during the 
first half of an extra-uterine pregnancy; it is only by taking into con- 
sideration the palpatory findings and the data obtained from the his- 
tory, as well as the results of observation, that a doubtful case can 
be cleared up. 

The second question to be decided, namely, what operation is indi- 
cated, is not so difficult provided one is dealing only with the presence 
of the ovum in the tube, i.e., a tubal mole. In such ciagnosisofa 
cases the tube contains not only the ovum, but also more '^^^'^^ '^°'®' 
or less extravasated blood, which accumulates in the lumen of the tube 
or between the fetal membranes, and in part also flows out of the tube. 
In these cases the tube is dilated either in part or along its entire length, 
and sometimes loses its tortuosity and feels hard and tense to the touch. 
The tumor is recognized as a distended tube and not a hematocele by 
the fact that it corresponds to the tube in position, and frequently 
also in shape, and exhibits the same mobility as the tube. If the uterine 
portion of the tube is not involved, the junction of the normal seg- 
ment of the tube with the distended portion can be demonstrated. 
In every case a positive diagnosis that the ovum is situated in the tube 
requires the demonstration of a hard, distended segment of the tube, 
and the absence of large extratubal effusions of blood. The constantly 
recurring attacks of pain also indicate that the ovum has not yet escaped 
from the tube. 

A still further refinement in the diagnosis of interrupted tubal 
pregnancy for the purpose of differentiating between tubal abortion 
and tubal rupture is possible only in a few isolated cases, and has 
no special clinical significance because it does not affect either the 
prognosis or the treatment. 

The diagnosis of extra=uterine pregnancy in the second half unques- 
tionably presents much less difficulties. It is based chiefly on the 
demonstration of the fetus outside of the uterus. The first step should 
always be. to look for the fetus. As it usually lies in the gestation- 



160 



GYNECOLOGICAL DIAGNOSIS 



sac, the clearness with which the fetal parts can be recognized will 
depend on the thickness of the sac-wall. Sometimes they are recog- 
nized very distinctly through the thin walls of the gestation-sac, and 
their recognition is probably easiest when the fetus has 

Diagnosis 

in the escaped from its envelope and is lying free in the abdominal 

cavity, immediately beneath the abdominal wall. A fetus 
in an intraligamentary gestation-sac is more difficult to recognize, but 
even in this situation it can usually be felt more distinctly than in a 
case of mtra-uterine pregnancy. The recognition of fetal parts by pal- 
pation is especially easy when they occupy Douglas' space; for the 

sutures, fontanelles, as well as crepita- 
tion of the bones of the skull may often 
be recognized. The demonstration of 
the fetus is much more difficult when 
it is dead and the resulting changes 
have taken place. At first the fetal 
parts become so soft that they are 
difficult to feel through the abdominal 
wall; later, if calcification takes place 
in the outer layers of the fetus or in 
the fetal membranes (lithopaedion and 
lithokylephopsedion), it is of course 
easier to demonstrate the presence of a 
\ y \. I tumor, but the identification of a fetus 

V /is possible only in very rare cases. If 

the gestation-sac becomes necrotic and 

perforation into the neighboring organs 

portion on the right side in contact with the takes placB, its presencB may be recog- 

pelvic wall; lundus begins at the right aspect . . 

of the tumor; the head lies on the vaginal nizcd by the discharge of fetal boues 

vault, to the left of the cervix. The sutures 

can be distinctly felt, and parchment crepi- through the bladder, mtestine, navel, 

tation is present. ,, . , ,, _ it,- 

or abdommal walls, in addition to 
direct palpation of the fetus itself, fetal sounds and fetal move- 
ments are, of course, also of value for the diagnosis; the latter are 
characterized by their great distinctness, and the fact that they 
cause pain. Diagnosis by palpation is probably most difficult when 
the gestation-sac develops between the layers of the broad ligament 
and when a considerable period has elapsed since the death of the 
fetus. In doubtful cases resort may be had to radiography, which 
may, if the time of exposure is long enough, give a picture of the 
fetal skeleton, and thus at least demonstrate the presence of a 
fetus. Marschall succeeded in demonstrating the fetal skeleton even 
in the presence of calcified membranes; but in a number of cases 
radiography has failed. 




Fig. 84. — Left-sided Intraligamentary 
Tubal Pregnancy in the Tenth Month. 
P.-F. 'A. (Original.) Cystic tumor; vaginal 



SPECIAL DIAGNOSIS 



161 



If the presence of a child has been positively demonstrated, it 
remains to be decided whether it is intra- or extra-uterine. The 
examiner endeavors to palpate a fetus or ectopic sac lateral to the 
uterus. Success will usually depend upon the relation of the gestation- 
sac to the uterus. If the former is pedunculated, and the uterine 
portion of the tube is not involved, the outlines of the uterus can 
easily be made out, even when the ectopic sac is adherent to the 
organ. Difficulties arise, however, when it is intraligamentary, because 
in that case it grows close to the uterus, between the layers of the broad 
ligament, and occasionally even encroaches upon the muscle of the 
uterine wall, so that, as in the case of 
any other intraligamentary tumor, it is 
very difficult to distinguish the outlines 
of the uterus (Fig. 84). Successful pal- 
pation of the uterus depends also on its 
relation to the ectopic sac. If the latter 
is pedunculated, it is occasionally found 
in front of the uterus and behind the 
abdominal wall — under which condi- 
tions the connection between the uterus 
and the sac is readily recognized (Fig. 
85); but in most cases the uterus is in 
retroversion and can be quite easily 
outlined through the rectum. In intra- 
ligamentary tubal pregnancy the uterus 
is usually displaced to one side and for- 
ward, and lifted out of the pelvis by 
the growth of the ovum. Accurate 
examination under anesthesia is abso- 
lutely necessary for ascertaining these 

topographical relations. It must, however, be made with care, and the 
uterus must not be displaced with the tenaculum, as rupture of the 
sac might result. The introduction of the sound for the purpose of 
finding the uterus should, if possible, be avoided. Occasionally a 
circumscribed, firm resistance, corresponding to the placenta, can be 
demonstrated in the gestation-sac (Fig. 85). 

The diagnosis of extra-uterine pregnancy, particularly the differ- 
ential diagnosis from other tumors, receives additional support in the 
uterine changes incident to pregnancy. During the sec- 
ond half the uterus is always distinctly enlarged in all its diameters, 
and in intraligamentary tubal pregnancy the organ is often very much 
elongated; if the fetus is living, the consistency is very soft and the 
vagina appears bluish-red and soft. After the death of the fetus these 

11 




Fig. 85. — Right-sided Pedunculated 
Tubal Pregnancy in the Tenth Month, 
WITH Living Fetus. P.-F. %. (Original.) 
Tiie uterus is in anteposition, large and soft; 
along its right aspect a distinct area of resist- 
ance is felt, which can be outlined (placenta) 
and becomes diffuse farther down. On the 
left side the fetal back is distinctly felt; X 
indicates the position of the small parts. 



162 GYNECOLOGICAL DIAGNOSIS 

phenomena gradually disappear again, although they may be demon- 
strable for some time. In the breasts the same conditions develop as 
with intra-uterine pregnancy; and likewise after the death of the child 
puerperal changes take place in the breasts. 

In those cases in which the palpatory findings are not sufficient 
for a positive diagnosis, a lew of the data obtained from the history 
and the symptomatology may be utilized. The statements in regard 
to amenorrhea are uncertain in this condition, because it is frequently 
obscured by returning menstruation and irregular hemorrhages; in 
most cases, however, amenorrhea, at least for a short period, is present. 
On the other hand, in the fetal movements a new factor arises, for their 
unusual severity and the severe pain accompanying them often arouse 
the suspicion of extra-uterine pregnancy. The subjective symptoms of 
pregnancy are uncertain and often altogether absent. If some time 
has elapsed since the death of the fetus, menstruation returns, and 
the only statement obtained in such a case of uninterrupted extra- 
uterine pregnancy is that the patient some time before was pregnant, 
or thought herself pregnant, but that no delivery took place. 

Case 13. Mrs. B., aged 37. First menstruation at the age of 12 years; always regular, 
attended with pain. Married at age of 16; subsequent to this time signs of gonorrheal infec- 
tion. In 1887, two years after marriage, abortion in third month; this was followed by a 
period of sterility. In September, 1895, menstruation ceased; five montlis later painful fetal 
movements were noted which suddenly ceased in the eiglith month; in the nintli month a 
spongy structure (decidua?) and a certain amount of blood were discharged, accompanied by 
pain. Pain during the entire pregnancy; but no peritonitis, hemorrhages, or cramps. Soon 
after the menses returned, and since then have recurred regularly every three or four weeks. 
The tumor, which the patient herself felt in her abdomen, is said to have diminished con- 
siderably during the first five years; since then it has remained stationary. The patient 
complains of pain in the umbilical region and increased desire to urinate. 

Present Condition: Protrusion of the lower abdomen by a flat tumor, extending 
above the, navel and laterally a hand's breadth from the median line. Mobility very much 
limited; consistency very hard, in some places as hard as stone; cervix in the pelvic axis; 
uterus in retroversion behind the tumor; length 7 cm. The tumor can be felt through the 
anterior vaginal vault, where it ends in an angular projection of very hard consistency; no 
connection between the uterus and tumor is demonstrable. Radiography is negative. 

The objective findings render the diagnosis of extra-uterine pregnancy impossible, for 
nothing of a destructive character could be recognized in the tumor. On the other hand, 
the history was absolutely positive, and without it the diagnosis could not have been made, 
for a subserous fibroid would probably have been suspected. The diminution in the size of 
the tumor seemed to confirm the theory of a lithopajdion. 

The diagnosis was confirmed by laparotomy. The extirpated tumor, which lay 
free in omental adhesions, contaiiied fetal parts, which could still with some difficulty be 
recognized; the angular projection below was the calcified placenta. 

The disturbances in the course of extra-uterine pregnancy are im- 
portant in the differential diagnosis from intra-uterine gestation. They 
consist in the occurrence of irregular hemorrhages, usually of brief dura- 
tion, attacks of cramp in the abdomen, or more or less severe peritoni- 



SPECIAL DIAGNOSIS 163 

tis. Extra-uterine pregnancy very rarely goes on to the second half with- 
out disturbances of this kind. The diagnosis of fetal death is of course 
very much easier than in the first half; just as in intra-uterine preg- 
nancy, it is based on the absence of heart sounds, the difficulty of pal- 
pating the fetal parts, the cessation in the growth of the abdomen, 
and the diminution in the size of the breasts. The patient's statement 
that the fetal movements ceased suddenly — often with chills — also 
points to fetal death. 

In the differential diagnosis of extra=uterine pregnancy many 
different morbid conditions must be considered, because this clinical 
picture is encountered in many guises. Severe peritoneal collapse, 
with effusion into the abdominal cavity, may require Differential 

explanation; in another case a piece of discharged ovum Diagnosis, 

is presented for examination in order to decide whether abortion has 
taken place or the suspected material comes from the decidua of an 
extra-uterine pregnancy; again, the decision may have to be made 
between a tubal tumor of an inflammatory nature and pregnancy; 
in yet another case the physician must determine, after the presence 
of a fetus has been demonstrated, whether it is intra- or extra-uterine. 
Thus the diagnosis presents many different problems which cannot be 
solved from a single standpoint. I shall, therefore, take up in succession 
the differential diagnostications that are most important in actual prac- 
tice, indicating the proper method of arriving at a correct conclusion. 

1. Free internal hemorrhage and perforation peri- 
tonitis. The acute peritonitis which follows perforation of an abdom- 
inal organ (stomach, intestine, appendix, pyosalpinx), like rupture 
of a tubal pregnancy, is very frequently attended with 
sudden collapse, violent pain in the abdomen, and vomit- HemorrhTge 
ing. As a rule there is no great loss of blood, but merely ''"'^ PerUonlus" 
the escape of the contents of the ruptured organ, and 
accordingly the patients do not look anemic; apathy, yawning and 
air-hunger are usually not present; instead, they appear livid and 
have the anxious expression of peritonitis, while pain and vomiting are 
more prominent symptoms. If there still remains a doubt whether an 
internal hemorrhage or an effusion of the contents of an organ or an 
abscess has taken place, an exploratory puncture with not too small a 
needle should be made under aseptic precautions at a point where 
percussion has previously demonstrated the presence of an effusion. 
Either blood or purulent fluid will be obtained. The occurrence of 
blood with rare exceptions points to a ruptured extra-uterine preg- 
nancy, although occasionally even a large quantity of blood may have 
been shed from some other organ (uterus, liver or spleen). For this 



164 GYNECOLOGICAL DIAGNOSIS 

reason a positive proof of pregnancy is most desirable. If menstrua- 
tion has ceased, pregnancy is very probable; but the sign is not con- 
clusive, as rupture may occur before the cessation of menstruation; 
while, on the other hand, amenorrhea is also observed in pyosalpinx 
terminating in rupture. In the same way, pain in one side occurring 
before the accident may be due to the presence of an ovum in an abnor- 
mal situation, or to disease of other organs (tube, adnexa); hence 
there will always be some cases in which the diagnosis cannot with 
certainty be cleared up. The keystone of the diagnosis must always 
be the demonstration of blood in the abdominal cavity; as soon as this 
has been demonstrated — if necessary by means of an exploratory 
puncture — the supposition of a ruptured tubal pregnancy in the case 
of a sexually mature woman is justified, and the abdominal cavity must 
be opened. 

2. Interruption of a tubal pregnancy and early 
abortion. As the interruption of a tubal pregnancy in the early 
months is attended with labor-like pains, the discharge of fetal mem- 
brane and hemorrhage, and since these phenomena make 
aTubTi^Preg-° their appearance in a woman who states that she is not 
Ea"iT Abortion. Hieustruating and perhaps also presents subjective symp- 
toms of pregnancy, or possibly is herself convinced that 
she is pregnant, it is very natural that the physician should first think 
of abortion. If the ectopic sac cannot be demonstrated, or is mis- 
taken for something else, a diagnosis of abortion is frequently made 
and curettage performed, which is very apt to cause rupture of the 
extra-uterine sac with internal hemorrhage. This is a fatal diagnostic 
error, which we encounter but too often in practice; and yet the dis- 
tinction between the two conditions is not difficult. It is based on the 
demonstration of the extra-uterine gestation-sac, which is by no means 
difficult, provided the examination is made with sufficient care; for 
the tube, after the ovum is expelled, is filled with blood and surrounded 
by a hematocele which, although it may be small, is usually easy to 
palpate. Occasionally, especially if rupture has taken place early, the 
sac may be small and escape palpation. Hence in all cases in which 
the diagnosis of abortion is not absolutely positive, a second careful 
examination of the adnexa should be made when the woman is anes- 
thetized for curettement; if a suspicious tumor is found, no instrument 
must be introduced into the uterus. 

An accurate history may give valuable information. In abor- 
tion the labor pains are usually described as mild, dragging and press- 
ing sensations in the sacrum or in the middle of the abdomen; while 
in tubal pregnancy the pains are usually much more intense, are con- 
fined to one side, and are often repeated at long intervals. The nature 



SPECIAL DIAGNOSIS 165 

of the bleeding may also be of diagnostic value, inasmuch as a severe 
hemorrhage, with the formation of large coagula, is more in favor of 
abortion. Examination of the discharged portions of ovum may ren- 
der the decision quite easy. Every piece of fetal membrane is in favor 
of abortion; while the bi-lobed, complete clecidua, without oval con- 
stituents, is discharged by the uterus only during extra-uterine preg- 
nancy. But besides these two there are many other kinds of material 
from the uterus which cannot be identified even with the aid of the 
microscope. 

3. Uninterrupted tubal pregnancy and intra-uterine 
gestation with tumors of the adnexa. The physician is 
not infrequently called upon to make this differential diagnosis when 
there is an adnexal tumor in a woman who is in the second, 
or at the most, in the third month of pregnancy. As the xubafpreg- 
history points to pregnancy, and confirmatory objective intm-uteHnt 
signs are found in the uterus and vagina, the question AdnexaTxun^'re 
arises whether the tumor is an extra-uterine pregnancy and 
the uterus has at the same time undergone enlargement and softening; 
or whether the uterus contains the ovum, and the tumor in the adnexa 
is a small ovarian or parovarian cyst, a one-sided hydrosalpinx, or 
some other similar neoplasm. It is evident that the possibilities of 
error are limited by the fact that, on the one hand, the enlargement of 
the uterus must not be too great — hence most of the errors are made 
in the second month — if extra-uterine pregnancy is to be assumed; 
and, on the other hand, the tumor in the adnexa must present the 
peculiarities of a gestation-sac and its size must correspond to the 
period of pregnancy. Nevertheless, errors are quite frequent and 
usually consist in diagnosticating an extra-uterine pregnancy in cases 
of early intra-uterine pregnancy with tumors in the adnexa. Every 
gynecologist has probably made this mistake at one time or another, 
whereas the contrary mistake is exceedingly rare. The reason is partly 
that completely uninterrupted tubal pregnancy is extremely rare, and 
partly that every examiner, owing to the frequency of extra-uterine 
pregnancy and its gravity, is likely to think of it whenever he finds an 
adnexal tumor associated with pregnancy. The error is serious because 
it leads to laparotomy. As a matter of fact, innumerable unnecessary 
operations have been performed for this reason. 

The differential diagnosis should a priori incline to adnexal tumor, 
because unruptured tubal pregnancies are extremely rare. Too much 
dependence must not be placed on the palpatory findings in the tumor, 
because the examination must be made with extreme caution when an 
unruptured tubal pregnancy is suspected. As a rule, the symptoms of 
pregnancy in the uterus point the way to a correct diagnosis, because 



166 GYNECOLOGICAL DL\GNOSIS 

enlargement and softening are, of course, much more pronounced in 
intra-uterine than in extra-uterine pregnancy. As in every other case 
of doubtful intra-uterine pregnancy, the only way to make a positive 
diagnosis is to wait about four weeks (keeping a careful watch on con- 
ditions), and note whether the uterus shows a marked enlargement 
during that time. 

4. Ruptured tubal pregnancy and inflammatory 
adnexal tumors. The objective signs in these two conditions may 
be very similar, because in both the tube may appear gradually thick- 
ened, dilated, and hard. If, in addition, the recent tubal 

Pregnl'^cy ancT inflammation has produced softening and discoloration of 
AcfiTexSTumors. ^hc vagiual pcrtiou, which is by no means rare; if men- 
struation has ceased or been delayed; if, in the case of 
salpingitis, pains resembling labor pains have recurred at intervals on 
the affected side, the resemblance of the clinical picture to that of rup- 
tured tubal pregnancy becomes very great. Under such conditions I 
myself twice committed the error of mistaking an inflammatory tumor 
for a tubal pregnancy. 

Case 14. Mrs. L. Last menstruation beginning of October, when a hemorrhage 
occurred, at first shght but later increasing in severity, and lasting five weeks. The hemor- 
rhage was attended with irregularly recurring severe pains in the sacrum and in the left iliac 
region, which were frequently repeated, usually in the evening, and always associated with 
severe hemorrhage. Examination showed to the left of the uterus, which was not enlarged, ' 
a tumor having the shape of the tube and becoming smaller as it approached the median 
line, finally joining the uterus as a thin cord. No tubal changes on the right side; no soften- 
ing; no secretion in the breasts. On the strength of the history (hemorrhages and attacks 
of pain) and the physical signs (imilateral tubal tumor) I made a diagnosis of tubal 
pregnancy, but at the operation found an inflammatory tumor. 

The contrary error is also possible. Sittner says that Schauta among 77 cases diag- 
nosed inflammatory adnexal tumors in 7, in which laparotomy revealed a tubal pregnancy. 
Smith made the same error three times; and a number of other individual cases are reported. 

The differentiation between the two conditions cannot in most 
cases be based on a single infallible sign; the entire history and accu- 
rate palpatory findings must be taken into account. The data in favor 
of tubal pregnancies are: amenorrhea, severe attacks of pain recurring 
at intervals of days or weeks, protracted hemorrhages without much 
loss of blood. The physical signs are: distinct signs of softening, uni- 
lateral tubal changes, possibly with a soft mass in the neighborhood 
(blood). The factors in favor of inflammatory tumors are: greater 
uniformity of the pain, coincident catarrh, fever, severe pain on pres- 
sure, and involvement of the other side. The diagnosis may be at once 
cleared up by the discharge of a decidua. 

5. Ruptured tubal pregnancy and appendicitis. The 
similarity of the clinical picture is brought about by the fact that in 
inflammatory processes beginning in the appendix there are acute 



SPECIAL DIAGNOSIS 167 

attacks of pain recurring at intervals and followed by signs of peri- 
toneal irritation and, not infrequently, perforation peritonitis with 
sudden collapse; and, on the other hand, by the fact that the same 
phenomena may accompany the development of tumors on 
the right side, which are taken for blood tumors. Mistakes Pregnancy and 

„ ,.,,,. . rni T • Appendicitis. 

have often been made m both directions, ihe diagnosis 
Avill incline toward appendicitis if all the data and objective signs of 
pregnancy are absent and if the tumor is situated higher and more to 
one side, although occasionally an intraperitoneal effusion of blood may 
rise equally high. Anemia, slight jaundice, absence of fever, absence 
of all signs or previous irritation in the appendix are in favor of a rup- 
tured tubal pregnancy; while tenderness in the iliac region, the feeling 
of a tumor at the site of the appendix, and the objective demonstration 
of healthy adnexa on both sides, are against that condition. 

6. Retro-uterine hematocele and retroflexion of a 
gravid uterus. A retro-uterine hematocele may, generally speaking, 
be mistaken for any kind of tumor that may possibly occupy a retro- 
uterine position, and since it usually has a distinctly cystic 

., •! • i. i.j-U "il C J- Retro-uterine 

consistency, it is most apt to be mistaken tor a tumor Hematocele and 
which contains fluid. The conditions to be considered in a GravW uterus! 
the differential diagnosis are: tumors of the ovary and of 
the tube, and serous or purulent peritoneal exudates. In daily practice, 
however, the condition is much more often confused with retroflexion 
of a gravid uterus, not only because of the similar findings but also 
because the history is similar in both cases (amenorrhea, hemorrhage, 
pain resembling labor pains). The differential diagnosis of these two 
conditions has achieved unenviable notoriety in gynecology because it 
has in many cases been the cause of fatal accidents; for if, as has hap- 
pened again and again, a retro-uterine hematocele is mistaken for a 
retroflexed uterus, and attempts are made to correct it, the capsule of 
the hematocele is ruptured, and a fatal hemorrhage may result. I 
therefore advise the practitioner to give particular attention to this 
point. Theoretically the distinction between the two conditions is 
quite clear. In retro-uterine hematocele the entire uterus must always 
be demonstrable in front of the tumor; while in retroflexion of a gravid 
uterus only the cervix is found, and this directly continuous with the 
tumor. This sign must always be looked for, and in characteristic 
cases the correct diagnosis may often be made at once by digital 
examination. Very frequently, however, difficulties arise from the 
fact that the uterus is too near the hematocele and cannot be differ- 
entiated from it; or, if the cervix has attained a certain length, it may 
be mistaken for the entire uterus; not to mention cases in which accu- 
rate palpation is impossible on account of difficulties outside of the 



168 GYNECOLOGICAL DIAGNOSIS 

pelvis, such as thick abdominal walls, etc. Under these circumstances, 
the aid of other signs must be invoked. Occasionally the direction of 
the cervix is of value: in retroflexion of a gravid uterus, if the organ is 
not too large, it is low down and in front of the fundus, pointing back- 
ward and upward; while in anteposition of the uterus due to retro- 
uterine hematocele the external os usually presents directly downward. 
It is only when absorption begins that the cervix alters its position 
owing to the gradual retroversion of the uterus. In other cases a posi- 
tive diagnosis of retro-uterine hematocele can be made by finding the 
tubes immediately behind the abdominal walls — one of them usually — 
in a thickened condition. The uterine tumor itself often presents cer- 
tain differences which can be recognized with certainty. The gravid 
uterus is uniformly round in all directions and is often easily movable; 
while the hematocele above — especially in recent cases — has a very 
irregular outline, and in the pelvis also, owing to the irregular filling of 
Douglas' space or adhesions with the pelvis, the lower boundary may 
be irregular, These conditions can best be recognized by an examination 
through the rectum. The consistency of the gravid uterus is much more 
uniform than that of a retro-uterine hematocele, and does not change 
so quickly. Finally, a hint may be obtained from the history and from 
the symptoms. If there is no disturbance whatever, and the condition 
is normal, a retro-uterine hematocele is very improbable; while, on the 
other hand, a history of long-continued hemorrhages, particularly if they 
occur soon after a short period of amenorrhea or severe abdominal 
cramps repeated at intervals, is strongly in favor of an hematocele. 

7. Retro-uterine gestation-sac and retroflexion of a 

gravid uterus. A retro-uterine gestation-sac is, even more than a 

hematocele, apt to be mistaken for a retroflexecl gravid uterus. As an 

extra-uterine pregnancy is still in process of development, 

Retro-uterine . i o j r ^ i ; 

Gestation-sac the cUsturbanccs which lead to the formation of the hema- 

and Retroflexion i .n • i • i i • 

of a Gravid tocclc Will uot, as a ruic, DC mentioned m the history. 

There are no long-protracted hemorrhages and, on the 
other hand, the period of amenorrhea is longer and interrupted only by 
hemorrhages of brief duration. Abdominal cramps also are absent, or, 
if present, are feeble and of short duration. All the signs of softening 
are much more pronounced; the tumor is more uniformly round and 
has a much more distinctly cystic consistency than the hematocele. 
All these conditions in a given case produce a similarity to retro- 
flexion of a gravid uterus. The differential diagnosis from retroflexion 
of a gravid uterus is based on the same points as in the case of hema- 
tocele. Demonstration of the entire uterus in front of the sac is con- 
clusive; later the parts belonging to a young fetus may be found in 
Douglas' space. 



SPECIAL DIAGNOSIS 169 

8. Extra-uterine, and intra-uterine pregnancy. Mis- 
takes in regard to the site of implantation of the ovum are possible 
at any period of pregnancy. From the first to the last month the 
difficulties in the way of a correct diagnosis, in this re- 

•' . . . . Extra-uterine, 

spcct, may be so great that even a practised diagnostician and intra-uterine 

• c T 1 • 1 • 1 1 1 Pregnancy. 

may come to gner. In general it may be said that here 
again an extra-uterine pregnancy is more frequently incorrectly diag- 
nosed than an intra-uterine, and accordingly the number of unnecessary 
laparotomies is by no means small. This tendency to diagnose extra- 
uterine pregnancy too frequently is in part due to the fear of over- 
looking the condition. Any abnormality in the uterus that presents 
even a remote similarity to extra-uterine pregnancy is at first looked 
upon with suspicion, and then incorrectly interpreted. The mistake 
occurs in cases of pregnancy in which the diagnosis is absolutely posi- 
tive, both by the history and by the physical signs, but in which certain 
conditions in the uterus make it difficult to decide whether the fetus 
is developing within or outside of the uterine cavity. It is almost 
needless to say that confusion can arise in extra-uterine pregnancy 
only when the ovum is attached in the immediate vicinity of the 
uterus, or develops between the layers of the broad ligament and 
lies close to the organ. 

Diagnostic errors are more frequently due to certain special 
conditions in the wall of the gravid uterus: 

(a) The irregular contractions (see page 128), which cause the uterus 
to assume a very irregular shape, the contracted portions being hard 
and small, and the non-contracted portions large and flaccid. If the 
former happens to occupy the junction between the vaginal portion and 
the uterus, the examiner will receive the impression of a uterus of about 
normal size in that situation, and the soft portion along the side will 
appear to be a gestation-sac; if for any reason this condition is asso- 
ciated with hemorhrage, the suspicion of tubal pregnancy is increased. 

Case 15. Mrs. v. B. Last, menstruation November 7, 1903 ; when on Febrtoary 4, 
1904, hemorrhage occurred after an injury, a specialist was called. He believed that he felt 
a tumor in front of the uterus; in the subsequent examination, imder anesthesia, made for 
the purpose of confirming the diagnosis, he distinctly felt a soft tiunor, broadly attached 
to the uterus, which was hard to the touch and situated behind the tumor. As he made a 
diagnosis of extra-uterine pregnancy and declared that an operation was necessary, I was 
consulted. While on the next day the findings were exactly the opposite — the soft segment 
being on the right and the harder portion on the left — I could also detect without difficulty 
that the two segments together formed the uterus, which was in the ordinary state of preg- 
nancy. After six months the woman was easily delivered of a full term child. 

These contractions never last long and often disappear during 
palpation; if there is any doubt, it is easily removed by waiting and 
examining the patient again. 



170 GYNECOLOGICAL DL\GNOSIS 

(b) . The projections on the uterine wall over the site 
of implantation (see page 129) may also produce a picture suggestive 
of extra-uterine pregnancy, because part of the uterus undergoes eccen- 
tric enlargement and presents a soft consistency, while the part not 
occupied by the ovum appears harder and smaller. The former is then 
mistaken for the gestation-sac, and the latter for the uterus, and the 
longitudinal furrow in the uterine wall, which is so often associated 
with this phenomenon, heightens the mistaken impression. As the sup- 
posed gestation-sac is very close to the uterus, with a broad connect- 
ing surface, an interstitial, or at the most an isthmic pregnancy is the 
condition most likely to be suspected. A correct diagnosis can 
easily be made under anesthesia by demonstrating the gradual transi- 
tion from one portion to the other, and particularly if a labor pain 
occurs during the examination, the tumor at once gives the impression 
of a simple gravid uterus. Palpating the beginning of the adnexa 
beyond the soft tumor also confirms this diagnosis. 

(c) During the fourth to the sixth month fresh difficulties in the 
solution of this question arise on account of the marked softening of 
the lower uterine segment, as the result of which the gravid uterine 
body may form an angle with the cervix and occupy a lateral or poste- 
rior position with respect to it. In such a case the cervix, the upper 
extremity of which can be felt through the soft uterine wall, is mis- 
taken for the entire uterus, particularly if it is elongated and hard; 
and the body of the uterus, which lies to one side, for the extra-uterine 
gestation-sac. This is an exceedingly common error and is quite often 
recognized only during laparotomy performed for the purpose of extir- 
pating the supposed extra-uterine gestation-sac. The best way to avoid 
this error is through an examination under chloroform anesthesia. 
The body is brought into the median line and in this position, particu- 
larly if the fingers are carried upward along the lateral aspects, the 
transition to the vaginal portion is readily recognized. Another good 
way is to palpate with the examining fingers wide apart so as to grasp 
the vaginal portion between them, and then to push one of the fetal 
parts, the head if possible, between the fingers from above. By this 
manoeuvre it is easy to decide whether the fetal part is in the uterine 
segment or to one side. Often the diagnosis can also be assured by find- 
ing the round ligament and the ovaries. The history may give valuable 
information in so far as the absence of disturbances in the course of 
pregnancy up to the time of examination is in favor of intra-uterine, 
while the above mentioned disturbances point to extra-uterine gestation. 

Case 16. Mrs. H. In 1891, I was summoned to a large city in Russia to perform 
an operation in a case of extra-uterine pregnancy. On my arrival I found everj'thing ready 
for the operation. The history which I obtained from my colleague, a specialist of recog- 



SPECIAL DIAGNOSIS 171 

nized ability, aroused mj' astonishment because there had been no disturbance of any kind 
(no hemorrhage, no pain) during the five months that the pregnancy had lasted. Under 
cldoroform anesthesia I at once recognized the error. My colleague had mistaken the body 
of the uterus, which was displaced to one side and retroflexed, for the gestation-sac, and 
the cervix for the entire uterus. As soon as I elevated the body and brought it into the proper 
relation with the cervix, it became evident that the case was one of ordinary intra-uterine 
pregnancy. The junction between the cervix and the body was distinctly recognized along 
the lateral aspects. 

(d) During the last months the differential conditions become more 
and more favorable, although even at this time difficulties may arise 
if the gestation-sac, especially when it has developed between the 
layers of the broad ligament, is so close to the uterus that the latter 
cannot be demonstrated with absolute certainty. The median position 
of the cervix, or the course of the round ligament, occasionally supplies 
the necessary information. Not infrequently the thickness of the 
uterine wall overlying the fetal portions helps to solve the question 
whether the fetus lies within the thin gestation-sac or whether it is 
covered by the thicker uterine wall. There can be no difficulty in 
demonstrating the parts of a living full-term fetus if it is merely 
covered by thin fetal membranes; and, on the other hand, the 
diagnosis of intra-uterine pregnancy is positive if a muscular wall, 
or even one capable of contracting, is felt between the fetal parts 
and the palpating hand. Difficulties of various kinds, however, 
arise to mar the value of this sign. Thus in the case of ill-nourished 
multiparse, the uterine wall may be so thin that one apparently feels 
the fetal parts directly under the abdominal wall; on the other hand, 
there may be inflammatory thickening of the wall of the gestation-sac, 
or the latter may be so deeply placed that the fetal parts cannot 
be reached through the abdominal walls; or again the wall of the 
gestation-sac, in the case of intraligamentary pregnancy, may be 
considerably thickened by the connective and muscular tissue; and 
finally, the fetal parts themselves may no longer be palpable because 
of death and maceration of the fetus. The greatest difficulties in 
this respect are encountered in intraligamentary pregnancy when a 
long time has elapsed since the death of the fetus. 

Finally, if every means of settling this question proves futile, it 
may be permissible to make a cautious use of the sound in order to 
demonstrate whether the uterine body is empty. I consider this per- 
missible, however, only when the fetus is positively known to be dead. 
The diagnostic difficulties are illustrated by the following case: 

Case 17. Mrs. W. believes herself to be pregnant since September, 1887. In Octo- 
ber, 1888, the shape and distention of the abdomen were found to correspond to the 
last months of pregnancy. The abdominal tumor, which could be distinctly outlined, was of 
about the sliape of the gravid uterus; the surface was uniformly smooth, and the timior ex- 
tended upward beyond the navel. On vaginal examination, I found that the tumor extended 



172 GYNECOLOGICAL DIAGNOSIS 

into the pelvic inlet, where the fetal skull could be distinctly felt. The cervix occupied the 
left posterior quadrant and could be outlined only for a short distance. The history showed 
amenorrhea since September, 1887, and numerous irregular hemorrhages during the course 
of the pregnancy; two severe attacks of peritonitis; no discharge of decidua; and cessation 
of fetal movements in June, 1888, accompanied by clrills and another attack of peritonitis. 
The diagnosis lay between missed labor and intraligamentary or extra-uterine pregnancy. 
The history pointed to the latter, the physical signs favored the former. An attempt was 
made to demonstrate that the uterus was empty. The results of soiuiding were not posi- 
tive; it showed a length of 10.5 cm. The cervix was accordingly dilated with laminaria 
tents, and even then I could not introduce the finger beyond the internal os, but I could now 
determine with absolute certainty that the cervix was entirely separated from the gestation 
sac. Laparotomy showed an intraligamentary tubal pregnancy on the right side. 

Extraordinary diagnostic difficulties may arise when extra-uterine 
and intra-uterine pregnancy exist at the same time. This complication 
is not so rare but that it might occur in the experience of any practising 
physician. Up to 1904 Neugebauer collected 155 cases from the liter- 
ature, 19 of which occurred in the year 1903. A case of this kind is 
usually brought to the physician's notice under circumstances some- 
what like the following: An extra-uterine pregnancy has caused dis- 
turbances — such as internal bleeding, or attacks of pain with slight 
external bleeding — while the intra-uterine pregnancy continues to 
develop normally; or, less frequently, an intra-uterine abortion occurs 
while tubal gestation is still in process of development. Depending on 
the duration of the intra-uterine pregnancy, the latter is overlooked, 
and the entire process regarded as tubal; or the intra-uterine pregnancy 
is positively recognized and the internal hemorrhage is referred to some 
other organ; or a hematoma alongside of the uterus is mistaken for a 
neoplasm or an exudate. This last mistake, which is probably made 
oftener than any other, is the more serious of the two, because an oper- 
ation which would save the patient's life is not performed. 

On the whole, it is most important for the physician to demon- 
strate the presence of extra-uterine pregnancy, which must be done by 
the above mentioned signs, except that discharge of the decidua is 
absent. In some cases it may be possible to diagnose a coexisting 
intra-uterine pregnancy if the uterus is especially soft and enlarged 
and the vagina is very much softened and discolored, particularly if the 
case is one of ruptured tubal pregnancy. If the intra-uterine pregnancy 
is already so far advanced that it is recognized at the first glance, one 
must nevertheless adhere to the diagnosis of tubal pregnancy if the 
symptoms are marked, because rupture of a gravid uterus, which might 
produce a picture similar to that of a ruptured tubal pregnancy, 
is exceedingly rare during the early months. During the later 
months the intra-uterine pregnancy becomes more and more promi- 
nent, while the extra-uterine gestation-sac with the fetus, which is 
usually dead by this time, lies behind or to one side of the uterus. 



SPECIAL DIAGNOSIS 173 

As a rule, it is mistaken for a neoplasm, unless an accident reveals 
the presence of fetal parts within it. 

Weibel reports as follows concerning the diagnostications made in cases of this kind: 
In one case a correct diagnosis of both kinds of pregnancy was made before the occuiTence 
of any disturbance ; in 10 cases the diagnosis was made after the occurrence of rupture ; 
in 26 cases during abortion or part-urition; in 36 after abortion or parturition; in 25 during 
the operation on the tubal pregnancy; and in 8 after the operation for tubal pregnancy. 

It follows, therefore, that only in 11 out of 104 cases was the diagnosis correctly made 
at a time when the physician was still entirely master of the situation. 

Rarer Forms of Extra=uterine Pregnancy. In most cases the phy- 
sician will make the general diagnosis of extra-uterine pregnancy and, 
on account of its frequency, will be justified in assuming it to be tubal. 
Under specially favorable conditions, however, it may be possible to 
differentiate the kind of pregnancy in the living woman, for example, 
in the case of an interstitial or ovarian pregnancy, or one situated in a 
rudimentary cornu. Because extra-uterine pregnancy in the fimbriae 
and tubo-uterine pregnancy are anatomically so difficult to characterize, 
a clinical diagnosis is out of the question. 

Interstitial gestation, i.e., implantation of the ovum in that 
portion of the tube contained in the uterine wall, produces certain 
special signs which may possibly be recognized. The ovum develop- 
ing alongside the upper part of the fundus causes a marked upward 
displacement of the corresponding uterine cornu, which becomes more 
and more marked; while the other cornu is pushed downward, so that 
the uterus lies in an oblique position with the gravid cornu directed 
upward. Accordingly the origin of the adnexa on the two sides is very 
different; on the non-gravid side low, and on the gravid side high up 
on the gestation-sac (Ruge's sign). The round ligament passes out- 
ward from the gestation-sac, making it possible in some cases to dif- 
ferentiate it from a pregnancy in the rudimentary cornu. So far as its 
physical signs go, it most nearly resembles rupture of the gravid uterus, 
from which it may be distinguished, however, by the fact that rupture 
in the former almost always occurs during the first half of pregnancy, 
while in the latter rupture takes place during the later months. 

Ovarian gestation may be suspected clinically when, in the 
presence of a positively recognized extra-uterine gestation-sac, the 
tube is found free along its entire extent and without any connection 
with the gestation-sac. The physical signs, however, are hardly ever 
definite enough to make such a diagnosis. 

In contradistinction to the two last mentioned varieties, gesta- 
tion in a rudimentary cornu of the uterus presents an abnor- 
mahty which can always be positively recognized, albeit with great 
difficulty. The clinical picture and the physical signs may, it is true, 
be quite different, depending upon whether the gravid cornu has a 



174 GYNECOLOGICAL DIAGNOSIS 

short or a long pedicle, whether the fetus continues to develop or dies 
and is retained, and lastly whether the symptoms of rupture have 
already occurred. 

For the diagnosis of pregnancy in a rudimentary cornu it is 
necessary, in the first place, to demonstrate a tumor corresponding to 
a gestation-sac alongside the non-gravid cornu of the uterus. The 
pregnancy as such is easy to demonstrate objectively in the accessory 
cornu if the fetal signs make their appearance during the second half. 
During the first half the doughy consistency of the cornu may arouse a 
suspicion of the true state of affairs. If, as very frequently happens 
in the rudimentary cornu, the fetus dies, all signs of pregnane)^ soon 
disappear and there results a globular tumor on one side of the uterus 
which may in ever}^ respect resemble a neoplasm — either a solid ovarian 
tumor, if the connecting band is long, or a subserous myoma, if it is 
short and thick. Sometimes contractions occurring spontaneously, or 
following traumatic irritation, may reveal the pregnancy. In the main, 
the physical signs of a gravid rudimentary accessory cornu correspond 
to those produced by a simple gravid uterus, but there is considerable 
deviation of the tumor from the median line. In the beginning the 
gravid cornu is markedly oblique and situated to one side, gradually it 
rises out of the pelvis, and during the latter part of the time may be 
almost in the median line if the band which connects it with the non- 
pregnant cornu allows it sufficient mobility. The non-pregnant cornu 
alters its position in the same degree; at first it is oblique, but gradu- 
ally it is crowded more and more downward into a position of ante- 
flexion or retroflexion. The presence of a gestation-sac is also suggested 
by the signs of softening in the genitalia, in which the non-gravid 
cornu also takes part, undergoing slight enlargement and softening. 
After the death of the fetus these phenomena subside. In the history 
there is nothing characteristic to distinguish the condition from an 
ordinary pregnancy, if no symptoms of rupture have occurred; if 
rupture takes place, as happens in about half of the cases, the symp- 
toms resemble those of a tubal pregnancy. Not infrequently the dis- 
charge of the decidua assists in establishing the diagnosis of pregnancy, 
and its cylindrical shape, with only one cornual point and one tubal 
orifice, may confirm the diagnosis of a bicornute, gravid uterus. 

Another requisite for the diagnosis of pregnancy in a rudimentary 
cornu is the demonstration of the connecting band between the gravid, 
and the normally developed non-gravid cornu. The thickness of the 
connecting piece is subject to great variation, from the thickness of the 
thumb to a mere membranous plate, softened by the pregnancy and 
barely recognizable. It may be so short that the two portions of the 
uterus are scarcely separated, while in another case there may be a con- 



I 



SPECIAL DIAGNOSIS 175 

siderable interval between them. Hence the physical signs in a case in 
which pregnancy has been definitely established may be those of inter- 
stitial pregnancy; or, if the connecting piece is of uniform thickness, 
those of pregnancy in a bicornute uterus; while, on the other hand, 
if the connecting piece is long and thin, a pregnancy in the lateral por- 
tion of the tube or even in the ovary, may be simulated. In the last 
case the true state of affairs is revealed by the course of the round liga- 
ment, which shares in the general hypertrophy incident to pregnancy 
and is usually quite easily felt; it runs from in front upward to the fetal 
sac and usually loses itself in the anterior and upper part of the sac. 
In this way the enlargement is recognized as the uterus and is sharply 
distinguished from a tubal gestation-sac. 

Occasionally the coincidence of a double vagina may suggest the 
possibility of pregnancy in a uterus bicornis. The diagnostic difficulties 
in pregnancy in a rudimentary horn are shown by the following case: 

Case 18. Mrs. W. presents a tumor about as large as a man's head, round, very hard 
and firm, and under anesthesia exhibiting a moderate degree of mobility. The uterus is 
felt to the left of the tumor and separate from it, and has a length of 7 cm. ; the left adnexa 
are normal, the right cannot be felt; no softening or discoloration of the vagina. According 
to the objective signs, a diagnosis of a right-sided ovarian tumor (dermoid) would have to 
be made; but the history is absolutely conclusive of extra-uterine pregnancy. The woman 
was about 28 years old, had been married eighteen months, and had had her last menstrua- 
tion on the 10th of April, 1894; on the 11th of February, 1895, two flat, fleshy fragments, 
about 4 to 5 cm long, were passed. Four weeks later there was discharge of bloody mucus, 
and after that amenorrhea until the present time (beginning of May). On the 17th of Sep- 
tember, 1894, there had been distinct fetal movements lasting three weeks. Swelling of the 
breasts, which exuded milk, took place after. the supposed death of the fetus. Since January, 
1895, the abdomen is said to have diminished in size. From this history a definite diagnosis 
of pregnancy could be made, and the physical signs made it possible that the fetus had devel- 
oped in the extreme lateral portion of the tube, although the firmness and mobility of the 
gestation-sac were not in accord with this diagnosis. Laparotomy showed a gestation-sac 
almost as large as a man's head in the extreme lateral portion of the right rudimentary cornu, 
with the right adnexa and the round ligament inserted into its outer surface. The connection 
between the gestation-sac and the fully developed uterus was thin, muscular, and without 
any lumen; the fetus was macerated. 

Microscopic Diagnosis of Pregnancy. 

The diagnosis of pregnancy can either be made by the clinical 
signs, or it may be based on the result of macroscopic and microscopic 
examination. The anatomic diagnosis is based on two 

. . . . Products of 

different points. First, the recognition of the products conceptioa 

„ . . and Changes 

or conception, i.e., the letal parts; and, second, the inekientto 

demonstration of changes produced in individual mater- 
nal tissues by pregnancy, Either maternal or fetal parts alone, or the 
two together, suffice for the diagnosis. 

With respect to the macroscopic examination of the products of 
conception, an ovum expelled in toto is recognized by the villi which 



17G GYNECOLOGICAL DIAGNOSIS 

surround it, and by the contained embryo or its remains. During tlie 
earliest part of pregnancy the embryo may disintegrate and become 
in part absorbed; quite often nothing remains but the umbiHcal cord, 
Macroscopic with a suiall piece of the embryonal abdominal wall in 
Examination. ^j^p shixpo of a ycllowish-white particle. The remnant of 
the umbilical cord sufhces for the diagnosis. During the first weeks 
the ovum maj^ be expelled (1) free, without any envelope, or at 
most with a few small particles of the decidua basilaris (maternal 
pai'ts) clinging to the tips of the villi; or (2) the material presented for 
examination ma}' be a three-cornered structure, with a rough, uneven 
outer surface corresponding in shape to the lining of the somewhat 
enlarged uterine cavit}'; the structure is hollow, and on being opened 
is found to be slightly thickened and convoluted, but presents never- 
theless smooth, irregular polygonal fields, and punctate areas corre- 
sponding to the orifices of the uterine glands. This is the decidua; 
and its discharge assures the diagnosis. The rough, somewhat villous 
outer surface corresponds to the implantation site; the deepest por- 
tion of the altered mucous membrane always remains behind. Occa- 
sionally a minute scrutinj^ of the material discharged in abortion in the 
second or at most the third week, will disclose the ovum still adherent 
Ovule in to the expcllcd decidua (compare Fig. 100). The spot 

the Decidua. ^vhere the ovule is lodged (from | to 1 or 1| cm. in diam- 
eter) is usualh' slightly depressed at the centre and thickened at the 
periphery, and the surface is somewhat smoother than the surround- 
ing parts. In such a case, therefore, the ovum is expelled along with 
the uterine membrane altered by gestation, and the diagnosis is estab- 
lished. During the second to the third month it is rare that the entire 
lining of the uterus, with its connection with the fetus, is discharged. 
The ovum surrounded by the capsularis merely has a small 

Gestation . , , . . 

from Second to piccc of vcra attached to it, while most of the basilaris 

Third Month. . . 

adheres to the expelled specimen; hence, during the 
later months only parts of the maternal tissue and fetal parts are 
expelled. The products of conception, the ovum with its membranes, 
chorion and amnion, maj^ also be incomplete in these abortive dis- 
charges. Sometimes the embryo or fetus is absent and only the mem- 
branes are obtained during the second to the third month; after the 
second to the third month, the total product of gestation, as has been 
mentioned, is never expelled in conjunction with the entire altered 
mucous membrane. A variable portion of the mucous membrane, 
Maternal botli vcra aucl basilaris, always adheres to the uterine wall, 

^^'''^- the muscular laj'er is laid bare in small areas. — With 

regard to the macroscopic examination of the maternal parts a 
distinction must alwavs be made between the first and the second half 



SPECIAL DIAGNOSIS 177 

of pregnancy. The decidua reflexa, that part of the utorino mucosa 
which surrounds the ovum, is smooth and yellowish-white from fatty 
changes and the deposition of fibrin. Here and there it exhibits red 
marbling from the presence of small extravasations. The (a) Decidua 

surface shows large fiat depressions corresponding to Keflexa. 

the orifices of the enlarged uterine glands. The reflexa becomes fused 
with the decidua vera at its point of reflection, over the ovum. The 
decidua vera, expelled in early months of pregnancy, presents a num- 
ber of furrows which apparently divide it into polygonal (f,) Decidua 
fields of varying size. The uterine glands, which cannot ^'"'^" 

be seen with the unaided eye in the non-gravid state, are distinctly 
recognized as minute openings. The surface appears cribi'iform Tlamina 
cribrosa), cross-sections distinctly show enlarged vessels of the mucous 
membrane, and in its deeper layers, immediately above the muscu- 
laris, the dilated glands are visible. The mucous membrane in cross- 
section is seen to be distinctly divided into a compact upper, and a 
spongy deeper layer, and its thickness may be as much as j cm. — In 
abortions the decidua vera is usually detached in the deep layer of the 
compact, or in the upper layer of the spongy portion, and when 
expelled, appears rough and shaggy (see above). Demonstration of 
the decidua suffices for the diagnosis. 

The decidua basilaris (formerly called serotina) is practically 
never expelled by itself; it is connected with the ovum, to which it is 
firmly adherent, at the so-called placental site. It is, therefore, usually 
expelled with the ovum; but during the earlier periods of (c; Decidua 

pregnancy the greater part of it may remain behind in Basiians. 

the uterus, in which case the expelled ovum presents villi at the point 
where otherwise the decidua serotina (basilaris) would be found. The 
decidua basilaris forms the so-called maternal portion of the placenta 
in a full term pregnancy. If the decidua basilaris (serotina) remains 
behind in the uterus it is usually removed on account of some disturb- 
ances occurring after abortion, either with the curette or with the 
finger. In abortion the basilaris is often compressed and sometimes 
drawn out in length by the act of expulsion. The individual products, 
the villi or decidua, and the fetal or maternal parts, can usually be 
recognized separately by careful examination according to the above 
directions, and thus assure the diagnosis. If the individual parts are 
retained for some time in the uterus after abortion and become satu- 
rated with blood and compressed by the labor pains, the Moie, 
structures known as moles, or blood moles, are produced. — Bioodmoie. 
Unless the material expelled is definitely proved to be some fetal or 
maternal product of pregnancy, or of the changes incident to preg- 
nancy, the diagnosis between abortion and a mucous polyp or a myoma 

12 



178 GYNECOLOGICAL DIAGNOSIS 

saturated with blood, or coagula and masses of fibrin, must remain in 
doubt. Decidual tissue always assures the diagnosis of pregnancy, 
but does not tell us whether we have to deal with a tubal or a uterine 
gestation. — Hence the macroscopic diagnosis of pregnancy is based on 
the demonstration of fetal or maternal parts. — But there are certain 
structures of the uterine mucous membrane and of the uterus, such as 
necrotic myomata, or even blood-clots, which, owing to their villous 
appearance, resemble placental villi and likewise often closely resemble 
fetal parts in shape, so that it is impossible to make a diagnosis by 
macroscopic inspection. Even the material obtained by curettage in 
cases of retained decidual tissue may not be sufficiently characteristic 
for a macroscopic diagnosis. In such cases a microscopic examination 
is essential for a diagnosis. Although the latter must be the final resort 
in many cases, the macroscopic examination must nevertheless not 
be neglected, for it furnishes valuable information and renders the 
subsequent work of the microscopist easier. 

Microscopic The microscopic examination, like the naked-eye inspec- 
Examination. ^-^^^^ j^^^^ f^^^ j^^ object the demonstration of the prod- 
ucts of conception, or of alterations in the tissues incident 
to pregnancy. The important essentials for the diagnosis are the 
recognition of the villi (fetal parts) and the decidua 

Demonstration / j. i x \ 

of Fetal and of (maternal parts) . 

vrntoe'eidua.'' The shape of the chorionic villi varies in the dif- 
ferent periods of pregnancy; they are the carriers of the 
fetal blood-vessels, both afferent and efferent; are largest in the chorion,, 
where they originate; and divide and subdivide again and again down 
to their terminal branches. The simile of a "villous tree" is most apt. 
We can speak of the trunk and of the branching limbs. 

Chorionic Villi. ... .„. .. 

ihe Villous tree with its ramifications is situated between 
the chorion and the decidua basilaris; the trunk is attached to the 
chorionic part and the terminal branches to the decidua, while another 
part ends free in the open spaces of the villous tree. In the intervillous 
space the trunk is thickest at its point of origin, and the branches be- 
interviiious comc thinner and thinner as they undergo subdivision, the 
Space. thinnest parts being the terminal branches. Like the 

trees in a dense forest the trunks are far apart, while the terminal 
branches are close together. — Two parts are distinguished in the villi: 
the villous stroma, and the epithelial covering of the villi. The 
(a) Villous stroma (during the earliest stage) consists of connective 

Stroma. tissue, which usually has the type of embryonal tissue and 

resembles the stroma of the umbilical cord. — In the mucin-containing 
ground substance' (myxomatous tissue) of the stroma lie the cellular 
constituents, which are round, spindle-shaped, or stellate, with delicate 



SPECIAL DIAGNOSIS 



179 



processes that anastomose with one another. The stroma cells stain 
but faintly, even the nucleus does not take the stain well, and the 
villous stroma in a stained microscopic section accordingly appears 
translucent and pale. The villous trunks and the larger branches con- 
tain the arteries, which have well-developed muscular walls, while the 
veins are very wide. As the terminal branches of the chorionic 
villi are approached, the vessels lose their arterial and venous 
character, and the terminal branches themselves consist merely of 

capillaries with a distinctly recogni- 
ze __-- zable endothelium. The latter form 




fe-' ^^ ^%S\ 



.t'^ 








1M:S# 



mmw ^mf& 



^ ^^ 






.( ,■ 






Fig. 86. — a. Villous Tree, from the first to the second month of pregnancy. 6. Villous tree at 
the end of pregnancy, c. Villous tree (six months), showing the villi dipping down deep into the maternal 
tissues, i.e., the vessels. (Original.) 



a small-meshed capillary network, and gradually unite again to form 
larger veins in the large villous trunks. The veins bring the arte- 
rial blood back to the fetus. — As in the pulmonary alveoli the vessels 
project somewhat into the lumen, so the capillaries in the terminal 
branches come close to the surface and often produce a slight bulging 
of the epithelial investment. The structure of the stroma varies some- 
what at the different stages of pregnancy. During the early stages the 
term myxomatous (embryonal tissue) is quite descriptive; during the 
later months, especially in the larger trunks, the stroma assumes the 
character of a firm, fibrillar, fibrous connective tissue. During the 
early stage of pregnancy the villi are short in comparison to the later 
stages, thicker, more shapeless, and show less ramification (Fig. 86, a). 



180 GYNECOLOGICAL DL\GNOSIS 

In the earliest stages the vilU are small, bud-like, epithelial prod- 
ucts, which invade the chorionic tissue along with the chorionic 
vessels — the mesodermal connective tissue grows into the ectoblast. 
— The most abundant ramification of the villous tree, and at the same 
time the greatest attentuation of the terminal bi'anches (Fig. 86, b), 
is seen at the end of pregnancy; in the early stages there is slight 
ramification and the terminal branches are thick and strong (Fig. 86, 
a). While even the gross structure of the stroma necessitates a com- 
parison between the earliest and the latest stage, such a subdivision, 
according to the various periods of pregnancy is particularly indicated 
in the study of the epithelial investment. 

As compared with its appearance during the later months, the 
epithelial covering of the villi possesses a special composition during 
the early months of pregnancy; the period of pregnancy can be inferred 
,,, ^ . ^ ,. , from the character of the villous epithelium. Hence the 

(6) Epithelial _ ... . . 

Covering of villous epithclium is of considerable importance in the 

the Villi. 1 • . n ■ 1 r. • T • 

decision of certain definite diagnostic questions as, for 
example, between abortion and a pregnancy of some duration. Let us 
first study the villous epithelium of the first two to two and a half 
months. At this time the epithelial covering consists of two parts, and 
the earlier the pregnancy, the greater the difference. The 
FirsrTw*oto first part, the external covering, which separates the 
h^if M^otthT" ^^^^^ from the intervillous space, is a finely granular and, 
Diltir'^uisire'd therefore, somewhat opaque mass of protoplasm, which 
stains fairly well and contains here and there some vacuoles 
and many round or approximately oval nuclei. The nuclei stain well; 
they are arranged in a single row, side by side; but the earlier the stage 
of pregnancy, the greater the probability of having two nuclei super- 
imposed one upon the other. No cellular outlines are to 
be seen anywhere in the mass of protoplasm, which covers 
all the villi and their entire ramification and is distinctly seen at the 
chorion, where it forms the boundary between the villi and the inter- 
villous space. It also covers part of the basilaris, encroaching on its 
surface from the villi which adhere to it. The protoplasmic mass, 
without cellular outlines, is found during the entire duration of preg- 
nancy, but its thickness diminishes and the shape of the nuclei changes. 
— During early pregnancy, which will be discussed first, the thickness 
of the mass is quite considerable and fairly uniform on the trunk and 
on the branches of the villous tree, being about twice the diameter of 
the round, or approximately oval nucleus. The protoplasmic mass 
without cellular outlines, which covers the villi, represents a syncytium: 
the epithelial investment is briefiy called the syncytial covering of the 
villi, or simply syncytium (Fig. 87). 



SPECIAL DIAGNOSIS 



181 



The second part of the villous epithelium is formed of cells 
which he underneath the syncytium; the more recent the pregnancy, the 
more distinct is this cellular layer. It consists of pale, vitreous, trans- 
lucent elements, often resembling squamous epithelium, the 2. Ectodermal 
villous body of which does not take the stain, while the ^^"^' 

nucleus stains very well. — In the microscopic picture, even under low 
magnification, the two layers and the subjacent syncytial layer are 
readily distinguished by the different tingibility of the individual parts. 
This second layer is a true cellular layer; but occasionally the individual 
elements form a bulging, here and there, so that it appears as if the cells 
were pressed into the stroma of the villus instead of its surface. This 



i 5 -''■•>-?.., 



ff?^ 








Fig. 87. — Transverse and Longitudinal Sections of Villi (fourth to fifth week). Syncytial (epi- 
thelial) processes — some of them lying free — Langhans' (ectodermal) cellular layer under the syncytial covering 
of the villi; proliferation of Langhans' cellular layer with syncytial elements connecting the two villi. (Original.) 

second layer, which consists of distinctly separate elements, is called 

the ectodermal layer or Langhans' cellular layer. It was formerly 

erroneously supposed that this second layer was fetal in 

origin (hence 'ectodermal';, while the syncytium was Jyncyt?umand 

maternal. The epithelial covering of the villi (syncytial ^'^*°'La™r^ 

and Langhans') is fetal in origin; the so-called ectodermal 

cell (Langhans' cellular layer) forms the matrix of the syncytial layer 

(Spuler). This ectodermal layer possesses a diagnostic value, as the 

typical, distinctly regular arrangement occurs only in the first two or 

two and a half months. 

The epithehal covering of the villi during the first two or two and a 
half months, which we have just studied, presents, in addition to the 
two epithelial layers (the syncytial and Langhans' cellular layer) certain 
other peculiar formations: 1. The so-called epithelial hoods at 



182 GYNECOLOGICAL DIAGNOSLS 

the ends of the villi; and 2. the epithelial processes, which may- 
be found at any point of the epithelial covering. — The epithelial hoods 
often cause considerable thickening of the sj'ncj'-tial covering at the 
^ ., ,. ,^ tip or extremit}^ of the villi, and mav contain large nuclear 

Epithelial Pro- . ^ o 

cesses, Epi- accumulatious. These structures bear an intimate rela- 

thelial Hoods. . ii-i-ii-i i- 

tion to the growth ot the villi (lengthwise growth) : the stroma 
grows into the protoplasmic mass and the latter continues to increase 
so long as the lengthwise growth of the villus goes on. The epithelial 
processes ("villous plugs") represent outgrowths of the sjnicytial 
investment and ma}^ present various forms. They may be long or short, 
attached to the surface like polypi or with a broad base, or connected 
with it b)^ a long-drawn-out pedicle, preparing thus for constriction and 
subsequent separation, "tear-shaped," "fig-like," etc. There is no 
doubt that many of the epithelial processes, which like the covering 

of the epithelial hoods are "syncytial," separate from the 

Separation of ^ _ j j i f 

the Epithelial protoplasiulc mass and remain free in the intervillous 

Processes. 

space. The}' may from this point reach the blood-vessels 
and enter the maternal circulation (see below). — The number of nuclei 
contained in the epithelial processes varies. The nuclei stain intensely 
and in the microscopic preparation, owing to their accumulation in 
the processes, produce conspicuous dark masses adhering to, or along- 
side of the villi. — The protoplasm of the epithelial processes is finely 
granular in the larger ones, and presents here and there some large, 
glistening corpuscles. In the smaller processes it is thin and drawn out 
more homogeneously, and contains vacuoles. 

The epithelial processes are also connected with the growth of the 
villi; but they more frequently represent, so to speak, the excess of epi- 
thelial investment, which undergoes a superabundant proliferation dur- 
ing the growth of the villus. As the growth begins to diminish, the 
epithelial processes (villous plugs) disappear; later the growth continues 
more slowly and more sj'stematically, but at the same time impercep- 
tibl}^ forward. The epithelial processes disappear between the fifth 
and sixth months of pregnane}^, i.e., at a time when the growth of the 
placenta has not as yet ceased. — Just as the ectodermal layer (layer of 
Langhans) maj^ be utilized diagnosticalh^ during the first two to two 
and a half months, so the epithelial processes represent diagnostic 
features, characteristics of villi from the first five to six months. 

In addition to the epithelial hoods and epithelial processes (the 
proliferation of the villous covering of the villi at their extremities and 
along the trunk), there are other most important and most interesting 
processes which affect our conception of the pathologic processes 
(chorionepithelioma malignum or syncytioma malignum). The}' are 
the benign proliferations of the entire epithelial investment (both the 



SPECIAL DIAGNOSIS 183 

syncytial portion and the layer of Langhans); the epithelial hoods and 
epithelial processes usually present only proliferation of the syncytial 
investment (see below, syncytioma benignum). — The villi of the early 
months (up to the sixth or eighth week) even to the naked eye, particu- 
larly if the villous tree is floated out in water, exhibit 
delicate, grayish-white round particles which may be Proliferation 
compared to the fruits of the villous tree hanging from . viiiou« oner- 
its branches, and represent proliferations of the villous Benignum. 

covering. The microscopic picture is somewhat less uni- 
form. — The villous branch, or villous hood, in the microscopic prepa- 
ration exhibits bud-like proliferations broadly attached to the villus. 
At first these proliferations retain their covering of syncytial proto- 
plasmic mass which, however, is visibly distended, as if it were torn in 










b 



Fig. 88. — Apex of a Villus ffourth to fifth week) : a. Proliferation of Langlians' cellular layer ; bxid-like 
eruption of the proliferation into the inter\'illous space. f>. Higher magnification. 'Original.; 

places. One gets the impression that the protoplasmic envelopes were 
trying to separate. Thej'' cover a mass of cells which is distinctly seen 
to be connected with the layer of Langhans — vitreous, translucent 
elements with nuclei that stain much less deeply than the nuclei of the 
syncytial masses. — We have to deal with a proliferation of Langhans' 
layer only, causing distention and attenuation of the overlying layer. 
Proliferation of this kind is also seen at points where Langhans' layer 
has broken through the syncytial investment: syncytial derivatives 
are found in the accumulation of Langhans' cells TFig. 88, h). As the 
villus continues to grow, large masses of cells, which can be seen with 
the naked eye and which we have just compared to the fruits of the 
villous tree, are produced. — These proliferations may cause agglutina- 
tion of adjacent villi at their apices CFig. 87); the bifurcations of villi 
due to division of the apex may be filled with these proliferations of 
the syncytial covering. As a rule the proliferation of the cells of Lang- 



184 



GYNECOLOGICAL DIAGNOSIS 



hans preponderates; the syncytial parts are apparently more passive, 
although since the proliferation is often very great, it is possible that 
the syncytial portion also takes part in it. — If we call the epithelial 
covering briefly 'chorionic epithelium,' since the syncytial portion is a 
derivative of the layer of Langhans, we may say that the chorionic 
epithelium consists of two layers: the ectodermal (in close appo- 
sition to the villous stroma), and the syncytial layer, which every- 




-ft" 










Fig. 89. — Vilt.i at the End of Pregnancy: Syncytial covering very thin ; Langlians' layer, celluJar 
layer, no longer demonstrable; arrosion of the maternal vessels, encroachment of the villi on the lumen. The 
decidua basilaris contains a few so-called syncytial wander-cells. (Original.) 

where covers the villi. — Hence these epithelial proliferations may 
be designated chorionepithelioma benignum (in contradistinction to 
chorionepithelioma malignum). — These epithelial proliferations will 
be referred to again in connection with the attachment of the chorionic 
villi to the decidua basilaris (serotina), and also in connection with 
hydatid mole. 

There is no doubt that the difference in the appearance of the 
various epithelial layers — the syncytial and the ectodermal — is 
very conspicuous, and that for a long time it was owing to this differ- 
ence in the appearance that the two layers were supposed to have a 



SPECIAL DIAGNOSIS 185 

different origin. It is only when the syncytial layer comes in con- 
tact with the contents of the intervillous space, and in pursuance 
of its object, a complicated not yet fully understood metabolism, 
that its appearance becomes different from that of the matrix (the 
ectodermal layer). — 

But little need be added to the above description of the villi or 
villous epithelium of the first two to two and one-half months to make 
it fit their appearance from the third to the sixth month. Until the end 
of this period the villi continue to increase in length, and 

■^ Villi from the 

the picture of the later placenta is produced. On the whole. Third to the 

, .„. . . - , . , , , . . Sixth Month. 

the villi, m spite or their growth, become thinner owing to 
the constant subdivision. The stroma assumes a more fibrous character. 
The vessels, which during the early stage of pregnancy do not exhibit 
a distinctly arterial structure within the villi, begin to have thicker 
walls. The epithelial covering toward the end of the sixth month 
diminishes in thickness and the nuclei become somewhat smaller and 
stain intensely. Many epithelial processes are still present, but they 
also are smaller; in a stained microscopic preparation (examined under 
low magnification) they appear as small particles of pigment on and 
between the villi. — The epithelial mass no longer contains Langhans' 
cells (no ectodermal layer). The thin, syncytial investment is 
apparently in direct contact with the stroma. — 

The villi from the sixth month to the end of pregnancy go through 
further changes in length, in the development of the blood-vessels and, 
by further ramification, in the calibre of the terminal branches, which 
become attenuated. — Before this period Langhans' ecto- 

Villi from the 



dermal layer disappears; at this time the epithelial sixth Mo^th to 

the End 
Pregnancy. 



processes also disappear completely and the epithelial ^^^ ^""^ °^ 



investment likewise becomes more attenuated and assumes 
a different appearance. — Whereas previously the covering of the villi 
was practically uniform, it becomes thinner, and often irregularly thin 
during the last months; in some places it is reduced to a minimum, and 
here and there it appears interrupted. As, however, it retains its marked 
tingibility, the deeply stained epithelial covering contrasts sharply 
with the paler, imperfectly stained stroma. — In microscopic prepara- 
tions the picture often appears patchy on account of the varying 
thickness of the epithelial layer. 

By keeping in mind this picture of the chorionic villi, and the 
changes that take place at the various periods of pregnancy, it will be 
found easy to demonstrate under the microscope those portions of the 
fetal constituents which have a diagnostic value. The presence of 
fetal constituents indicates pregnancy, since villi, being fetal constituents 
(products of gestation), cannot exist without pregnancy. — 



186 



GYNECOLOGICAL DIAGNOSIS 




In, addition to the above description there are to be mentioned 
certain changes of the fetal parts (vilU), lest a failure to recognize these 
changes lead to an error in diagnosis.— They are the changes which are 
produced by the inclusion of villi in blood-clots, decidual 
inthr '""^''^ masses and fibrin. The most important change consists 
Blood-clot. .^ ^ ^^^^ ^^ ^^^^ syncytial covering (Fig. 90); enclosed in 

blood or blood-clots, it first undergoes granular degeneration and is 
finally absorbed. In places it may be preserved in the form of small 
patches r but as a rule the villi, which previously were easily recognized 
by the well-stained epithelial covering, remain within the coagula, 
fibrin or decidual masses, appearing as pale, translucent areas, in which 

some stroma-tissue can still 
be recognized, but which 
: '^ by their translucent char- 

acter, as well as by the 
shape of the areas, suggest 
chorionic villi. One who is 
familiar with the picture 
will at once recognize the 
remains of the villi, hence 
the importance of becoming 
familiar with this villous 
alteration (Fig. 90).— The 
syncytial investment is oc- 
casionally retained in hyda- 
tid moles, in which chor- 
ionic villi, even when they 
are included in fibrin or 
decidua, may exhibit con- 
siderable proliferation of the epithelial covering (see below). 

Having studied the above retrogressive processes in the syncytial 
investments, let us now consider the progressive processes in the epithe- 
lial covering — the above-mentioned epithelial proliferations in hyda- 
tid moles. — The processes which lead to the conversion of 
the villi into hydatid moles belong to the earliest period 
of gestation when the ovum is beginning to attach itself 
at the site of implantation. As a rule the entire ovum 
is affected; sometimes, however, small portions only of 
the fetal envelope undergo "hydatid" change, the surrounding parts 
remaining normal. — The cause of this metamorphosis is not known. 
The etiological connection with numerous lutein-cells in the ovary has 
never been demonstrated. There is much to disprove the theory, 
particularly in the case of completely circumscribed metamorphosis 




Fig. 90. — Placental Remains (after abortion) : Villi en- 
closed in fibrin and blood, having lost their syncytial covering ; 
the free villi witli epithelial processes have retained their cover- 
ing ; the section also shows islands of decidual tissue. (2d to 
3d month.) (Original.) 



Progressive 
Processes in 
the Epithelial 
Covering 
of the Villi. 



SPECIAL DIAGNOSIS 



187 



Hydatid Mole. 



of individual segments into hydatid mole (degeneratio hydati- 
d s a circumscripta) . — Macroscopically the hydatid mole is easily 
recognized by the grape-like structures of variable size; 
large and small cysts connected here and there by delicate 
strands of tissue forming a characteristic picture. Indeed a single 
cyst ("berry," "hydatid cyst") which has been discharged from the 
uterus is enough after a little practice to suggest the diagnosis to 
the examiner. Any one who has 
had his attention called to these 
structures cannot fail to recog- 
nize them. If a shapeless mass 
of blood-clots containing cysts 
(m o 1 a h y d a t i d o s a ) is dis- 
charged, naked eye inspection 
may not suffice and a micro- 
scopic examination must be made. 
This very often shows the most 




;^=^. 



'---icrfa'' 



^^^ 



i^^ 



/ 



Fig. 91. — Villi of Hydatid Moles: a. Somewliat collapsed villus, witli central softening proliferations 
of the syncytial and ectodermal (Langhans) cells. 6. Hydatid mole — central liquefaction ; the villus rests 
on the decidua basilaris ; all around the villus, proliferation of the epithelial (fetal) investment, particu- 
larly well developed at the decidual junction ; proliferation of the ectodermal cells and so-called syncytial 
wander-cells. (Original.) 

interesting epithelial proliferative processes, which, as before mentioned, 
afford a key to the genesis of malignant forms (chorionepithelioma 
or syncytioma malignum). — It is difficult to decide whether the 
formation of hydatid mole is due to primary disease of the 
stroma or to primary disturbance of the epithelium; the 
former is more probable. The villous tissue presents irregular prolifer- 
ations. Constrictions are produced in the form of delicate cords con- 
necting the spherical enlargements which later become cystic. The 



Hydatid Mole. 



188 GYNECOLOGICAL DIAGNOSIS 

size of these connecting bands increases with their distance from the 
extremity of the villus. This type of proliferation points to a primary 
connective tissue origin. — In the proliferated, mucin-containing tissue 
^ . , ,. , softening and liquefaction occur at the centre, and a bunch 

Epithelial o i ) 

Proliferation in of cysts may prcscut first an epithelial covering, then a 

Hydatid Mole. , „ . . , , , , 

layer oi connective tissue apparently embryonal, and cen- 
tral liquefaction; in the stroma which is still preserved at the periphery, 
as elsewhere, large round or stellate elements, with large nuclei and a 
relatively large quantity of intercellular substance, are found; neither 
Softening of the cell-bodies nor the nuclei take the stain well. — Differ- 
the Stroma. euccs are observed in the epithelial covering. In some cases 
there is an apparently normal syncytial layer overlying the ectodermal 
layer; at another place in the immediate vicinity there may be irregu- 
lar proliferation of the epithelium — the cells of Langhans proliferate, 
apparently break through the syncytial layer, and continue to grow 
beyond it in places, so that the syncytium is found in the midst of the 
proliferated tissue as well as on the surface. Along with the prolifera- 
tion of the cells of Langhans the syncytium apparently breaks up, in 
some cases, into large solitary elements (Fig. 91, 6). A conspicuous 
feature in this proliferation are the large vacuoles often found side by 
side (Fig. 91, a). — These epithelial proliferations are sometimes very 
slight and at others completely surround the berries. — The descendants 
of the epitheluim may also proliferate into the stroma-tissue of the villi 
and are in that case regarded as forerunners of the existing or impending 
malignant syncytioma (Neumann). 

Of the changes due to pregnancy in the maternal parts the most 
important from a diagnostic standpoint is the formation of the 
decidua. — At the beginning of gestation, and under its influence, the 
Decidua uteriue mucosa is rapidly converted into the so-called 

Formation. mcmbraua decidua, or briefly, decidua. — The change that 

is brought about in the uterine mucous membrane by gestation is recog- 
nized in the constituents of the mucosa: in the epithelial portions (sur- 
face and uterine glands) and in the stroma (in the stroma-cell). Under 
the influence of pregnancy the stroma-cell becomes the decidual cell. 

A. The effect of pregnancy on the epithelium is variable, de- 
pending on whether the surface or the glandular epithelium is affected, 
and it varies also in the different periods of pregnancy. — In the sur- 
^ . face epithelium the change is merely a change of shape; the 

Epithelium: (o) Cylindrical, well-staining elements, with a centrally situ- 

On the Surface. . n i i , 

ated nucleus that also takes the stam well, become shorter, 
appear more cuboidal, the arrangement of the elements is somewhat 
more irregular, and the tingibility diminishes. As the uterus becomes 
greatly distended by the growing fetus, this change in the shape of the 



SPECIAL DIAGNOSIS 



189 



r^ 



cells increases; with the enlargement of the uterine cavity and the 
accompanying enlargement of the uterine surface, the epithehum 
becomes shorter, almost flat, and directly attached to the surface like 
endotheUum. — As a result of the adhesion which often occurs later be- 
tween the decidua vera and the decidua reflexa, the surface epithehum 
disappears altogether. The surface epithelium is of no par- (6) in the 

ticular diagnostic importance.— The changes that take place uterine Glands. 
during pregnancy in the uterine glands, on the other hand, depend 
chiefly on the period of pregnancy and are particularly important for 
the diagnosis of pregnancy in 
the first months. They may 
throw light upon the question 
whether or not an abortion has 
taken place. — The alteration of 
the uterine mucous membrane 
during the first months of preg- 
nancy consists, in the first place, p~-^' 
of an enormous increase in the ^ ^ 
thickness, which may be 1^ cm. \ 
and more. Macroscopically (see |? 
above) the raucous membrane |:|f 
presents an upper compact, and 
a deeper, spongy layer, while the 
microscopic picture resembles 
that of glandular endometritis; 
the uterine glands in the com- 
pact portion are compressed and 
thin, and represent the narrow 
ducts of the greatly dilated and 
closely aggregated glands in the 
deeper, spongy portion (Fig. 92). 
— The epithelium of the com- 
pressed, narrow excretory ducts is short, cuboidal and without special 
significance; in the spongy part, where the glands are greatly dilated 
and closely packed together, a most interesting change is often observed 
in the epithelium. While these changes are not pathognomonic of preg- 
nancy they occur so often in that condition that they cannot be denied 
a certain diagnostic importance. 

The glands are converted into Opitz-Gebhard glands. Both 
investigators, but more particularly Opitz, have pointed out these 
alterations. Whenever it is found in typical form, pregnancy must at 
least be thought of in connection with the etiology, and the diagnosis 
of pregnancy must be considered. — The conversion of the uterine 











■"i^ 



^r 



m 1-3- 






Fig. 92. — ^Decidu.a. Vera: In the deeper layers the 
greatly hypertrophied glands are seen (Opitz-Gebhard's 
alteration). (Original.) 



190 GYNECOLOGICAL DIAGNOSIS 

glands into Opitz-Gebhard glands consists in an interesting alteration 

of the epithelium and its structure (Fig. 93, a, b, c). — Instead of a 

simple, cylindrical epithelium, the glands present considerable prohfer- 

ation of the epithelial cells: on the walls of the glands 

1 ransformation _ _ ' " 

into Glands of projectious or ledges are formed, which in cross-sections 
(Opitz- look like papillae, and around these ledges, or papilla-hke 

projections, the epithehal cells are grouped in a somewhat 
loose arrangement. There results a palisade-like structure; the cells over- 
lap one another and form several layers. In addition to this curious 
multiplication, this stratified arrangement of the cells with a loosening 
of their connections, certain other changes take place in the cells them- 



^. 






^^'«K , -.-.^^^3*«t-, 



r^%. 



^X«OK '5 




'1 • '«. 











^^^^^s^s*: 



Fig. 93. — a and 6. Circumscribed Changes of the Glands in Pregnancy : Part of the epithelial 
covering is unchanged ; the other part shows Opitz-Gebhard's proliferation, c. Epithelial proliferation after 
Opitz-Gebhard under high magnification. (Original.) 

selves. In the first place the shape becomes cuboidal or round; in the 
second place they take the various stains less readily than before. At 
first the alteration appears like an ordinary proliferative process; later, 
the picture suggests a beginning proliferation with desquamation and, 
finally, necrobiotic processes. 

There is no doubt that these peculiar processes may be in some way 
connected with pregnancy; the irritation which in inflammatory pro- 
cesses leads to the production of identical, or very similar formations 
may be exerted also by pregnancy. — Interesting as are these changes in 
the glands during pregnancy, they are not specific, and the glands cannot 
be described as "glands of pregnancy" in the strict sense of the term. — ■ 

During the later months of pregnancy the proliferation of the 
uterine mucous membrane (decidua vera) falls behind the enlargement 



SPECIAL DIAGNOSIS 



191 



Change in the 
Mucous Mem- 
brane during 
the Later 
Months of 
Pregnancy. 








of the uterus (Figs. 94 and 95). The decidua vera is spread out and 
becomes thinner, and a distinction between a spongy and a compact 
portion is no longer possible with the unaided eye; in the microscopic 
preparation there are seen in the deeper layers cleft-shaped 
vacuoles which correspond to long-drawn-out uterine glands, 
while here and there the epithelial covering is still dis- 
tinctly visible. — The Opitz-Gebhard • glands have disap- 
peared; they are still preserved in that portion of the birth 
canal which even in the 8th or 9th month has not yet become involved 
in the general dilatation of the uterine cavity (see below), and which, 
with the cervical canal, still exhibits the structure of a canal (Fig. 102). 
Here the uterine mucous membrane is not as yet spread out as in the 
body of the uterus, and therefore the Opitz-Gebhard glands, or so- 
called "glands of pregnancy," persist for some time longer; whereas,. 
owing to their irregular, i. e., 
relatively vigorous growth, 
they have disappeared from 
the upper layer. — As the 
entire birth canal, as far as 
the internal os, is utilized 
for the formation of the 
uterine cavity and for the 
reception of the fetus at the 
end of pregnancy — indeed as 
soon as the upper portion of 
the cervix becomes dilated 
toward the end of gestation 

(almost regularly in primiparae, Olshausen) — the uterine mucous mem- 
brane of this portion also becomes so stretched that the true gland- 
formations disappear, leaving mere cleft-shaped spaces to represent the 
remains of the glands. — The epithelial changes in the uterine glands 
during pregnancy, in the form of the so-called glands of pregnancy 
(Opitz-Gebhard glands), in spite of the interesting pictures which they 
produce, possess only a relative diagnostic value during the first months 
(particularly in abortion); during the later months they have none. 

The changes produced by pregnancy in the uterine 
mucosa affect in the first place the epithelial constituents 
of the membrane (surface epithelium and glands) and have 
been discussed. The second change affects the stroma and 
is the most important for the diagnosis of pregnancy based on the 
maternal parts — Conversion of the stroma cells into the decidual cells. 

B. The stroma cell of the uterine mucosa is a small round element 
in which the cell body cannot be recognized. There are also spindle- 



FiG. 94. — Uterine Mucous Membrane in the 9th month; 
of pregnancy, taken from tlie middle of the body ; greatly 
attenuated decidual layer ; the muscularis is still covered 
with a layer of unaltered tissue (uterine mucous membrane); 
on the decidua are seen the fetal membranes (amnion and 
chorion). (Original.) 



Change in the 

Stroma-cell 

during 

Pregnancy. 



192 



GYNECOLOGICAL DIAGNOSIS 



shaped cells which are also almost completely filled by their nuclei. As 
has been stated, the mucous membrane, owing to the similar appear- 
ance of its elements, is usually described as a lymphade- 

Stroma-cell , , *^ _ ^ . r 

Becomes uoicl, cytogBuous tissuc. — Under the influence of pregnancy 

Decidual Cell. j. o ^ 

the stroma-cell enlarges and becomes a large, delicate 
and finely granular element with indistinct outlines, round or approxi- 
mately oval in shape, and containing a large nucleus (Fig. 96, a). The 



/^■'^ 



;rAr-s,, 






\ \ 




] % 







Fig. 95. — Uterine Mccous Membrane in the 9th Month of Pregnancy immediately above the 
internal os; in the deeper layers the uterine mucous membrane has not yet become altered (does not present 
the appearance of decidua), and the uterine glands are seen. (Original.) 



tingibility of the nucleus particularly is diminished as compared with 
that of the simple stroma cell; hence the mucous membrane of preg- 
nancy, which consists solely of decidual cells, is faintly stained and in 
the microscopic picture appears pale and translucent. — The spindle- 
shaped elements are converted into large spindle-shaped oval elements 
with more oval nuclei. — Subdivision of the membrane into layers 
of round, decidual cells and spindle-shaped elements is, however, 
somewhat forced and too diagrammatic. — 



SPECIAL DIAGNOSIS 



193 












/» 



« «■ 



« 



'9 



"^^ 



&■ 



The supporting structure (intercellular substance) which accom- 
modates the stroma-cells, or in pregnancy the decidual cells, under 
normal conditions consists of a finely granular material in which the 
decidual cells are embedded as in a soft mass. — The intercellular sub- 
stance during pregnancy merits attentive examination because it 
sometimes becomes important in the differential diagnosis between 
membranous dj'^smenorrhea and pregnancy or decidual endometritis. — 
Pregnancy produces a decidual 
change in the greater portion of 
the mucous membrane, particu- 
larly in the upper portion; 
wherever the alteration takes 
place it is uniform: the cells are 
arranged side by side, separated 
by short intervals; the decidual 
cells are almost all of the same 
size, they occasionally have two 
nuclei without, however, being 
thereby altered in their general 
characteristics. — It is not possible 
to make a distinction between 
these decidual cells which sur- 
round the vessels and the 
more distantly situated 
cells; even in the earliest 
pictures of the mucosa 
in man the conversion of 
the uterine mucous mem- 
brane into decidua is 
everywhere uniform and b 

quite independent of the 
vessels. — The greater 
portion of the uterine 

mucosa indicates a decidual change, i.e., the uterine mucosa, which 
has been described above as divided macroscopically into a compact, 
and a spongy portion, shows the decidual change chiefly 
in the compact, upper portion. When the spongy portion 
is well developed, the stroma is not uniformly converted 
into decidual tissue in the deeper layers of the mucous 
membrane and around the glands; indeed the deepest 
layer, particularly in those cases in which the glands 
encroach somewhat on the muscularis, remains unchanged, or at least 
does not exhibit a characteristic decidual transformation. The glands 

13 



Fig. 96. — a. Decidoa Vera (3d to 4th month) ; the stroma- 
cells are converted into large decidual cells ; 6. higher magnifica- 
tion ; c. decidual cell (abortion) after death of fetus. (Original.) 



During Preg- 
nancy the 
Greater Portion 
of the Mucous 
Membrane 
Undergoes Uni- 
form Decidual 
Transformation. 



194 GYNECOLOGICAL DIAGNOSIS 

also and their epithelial cells do not take part in the alteration. An 
interesting condition is produced when only one part of the gland 
(the superficial part) shows epithelial change and is converted into 
half a gland of pregnancy (Figs. 93, a, h, and 102, h). — Such a finding is 
important for the decision whether or not the upper portion of the 
cervix becomes decidual during pregnancy (see below). — 

The decidual cell is found in the mucous membrane (whether it be 
decidua vera, basilaris [serotina] or reflexa) during the entire duration of 
pregnancy, even though fatty degeneration of the cells may occur 
early in the reflexa, and even though the cellular elements almost 
disappear when, as occasionally happens, the decidua reflexa and 
decidua vera become fused. 

The finely granular and indistinctly outlined decidual cells, which 
stain but indifferently, may undergo changes that are not without 
Change in the dlaguostic importance, as, e.g., the changes that take place 
StefSeit^f after fetal death.— The outhnes of the decidual cell 
of the Fetus. bccomc distiuct; the finely granular, smoky protoplasm 
becomes transparent and almost like glass; the nucleus is smaller, 
round, and more sharply outlined (Fig. 96, c). 

Whenever decidual cells are found, the diagnosis of pregnancy is 
assured — the diagnosis of pregnancy from maternal parts is based on the 
demonstration of decidual cells. 

The diagnosis of pregnancy is made by the fetal elements (villi) 
and the maternal elements (decidua), or by both. — If, after abortion or 
premature labor, the fetal membranes have not been discharged, if the 
uterus still retains the remains of chorionic villi with the 
is Made^by"'''^ decidua basilaris, or decidua vera, the resulting symptoms 
Matemafparts. ^^^J necessitate curettage or digital removal of the re- 
tained material. — In the remains of the abortion fetal and 
maternal elements can be demonstrated; conversely, if there is a doubt 
whether abortion has taken place, it will be cleared up by the demon- 
stration of maternal and fetal elements. — Whenever the uterus still 
contains villi, some of the decidua is also preserved. — When there are 
remains of an abortion, or there are placental polypi, which are usually 
retained for some time in the uterus, the changes which demand atten- 
tion are: (1) Those which occur in villi by their inclusion in fibrin or 
blood-clots; (2) those which occur in the decidual cells after fetal death 
(see above). — While it is an axiom that the presence of villi in the scrap- 
ings indicates the probable presence of decidual cells, the converse of 
this is not true. In exceptional cases, when the development of the 
decidua is cjuite marked, involution of the decidua — even in the absence 
of villi — may be delayed for some time, or the process of involution may 
lack uniformity; islands or, decidual tissue of variable size may persist 



SPECIAL DIAGNOSIS 



195 



in the midst of the regenerated portions of the mucous membrane (Fig. 
97). A most interesting picture is produced when the decidual islands 
consist onlj' of a few cells and are distributed over large areas of the 
mucous membrane. In the main the decidual cells disappear rapidly 
when the uterus no longer contains fetal tissue. — 

The decidual cell represents the stroma-cell of the uterine mucous 
membrane transformed by pregnancy; hence it is incorrect to speak of 
decidual cells in any other situation than the uterine mucosa. It 
is undeniable that in pregnancy greatly enlarged cells, resembling 
decidual cells, occasionally occur in various situations, as in the 
cervical tissue (Gebhard), in the vaginal portion, and in the entire 
extent of the uterus (underneath and on the peritoneum, Rob. Meyer). — 

As the name — 

.-.^^^^ 




'0.' f» 






eW 



decidua — indicates, 
the uterine mucosa, 
after the cessation of 
pregnancy and the re- 
moval of all the fetal 
parts, rapidly under- 
goes transformation; 
either it is expelled in 
the lochia in large or 
small pieces, or the 
cells regenerate and 
more or less perfectly 
regain their original 
state. — The large, fine- 
ly granular cells be- 
come smaller; the 
nucleus also contracts by the excretion of a fine protoplasmic material, 
which remains for a short time among the nuclei and is then absorbed. 
The regeneration of the decidual cells takes place gradually and 
goes on slowly, until the microscopic picture is no longer charac- 
teristic, and, finally, the original stroma-cell reappears. — A gradual 
regeneration of the decidua — of the decidual cell — takes 
place. — While a positive diagnosis of pregnancy is based on the 
maternal and fetal tissues — the villi and the decidua — it should be men- 
tioned also that the development of the blood-vessels in the decidua 
may suggest the probabihty of pregnancy. The capillaries which develop 
in the decidua of pregnancy are large and wide — at least their walls are 
formed only by endothelium, which is in contact with the decidual cells, 
in fact the decidual cells seem to form the vessel walls. Arteries or veins, 
except in the very early stages, are practically never demonstrable. 



Fig. 97. — Islands of Decidual Tissue in the uterine mucosa, which is 
in process of regeneration, or completely regenerated. 



196 GYNECOLOGICAL DL\GNOSIS 

Thus large blood-vessels or blood-spaces, filled with blood, and in cases 
of abortion often thrombotic, also point to a change due to pregnancy 
and may assume importance in a differential diagnosis (from decidua 
membranacea) . — 

A diagnosis of pregnancy by the microscopic demonstration of the 
maternal tissues (decidua) seems very simple, yet many mistakes may 
be made, as the uterine mucosa presents a number of cell-changes which 
appear to be decidua but in reality have nothing to do 
ir^'^ie^Dilgr with pregnancy. A familiarity with these changes is only 
Dec'idulicdis. acquircd by practice, which will enable the examiner to 
recognize them at the decisive moment. The stroma-cell 
which has been transformed into a decidual cell under the influence of 
pregnancy is not in itself specific, it is merely suggestive of pregnancy. 
The small round, or spindle-shaped stroma-cell, which is usually com- 
pletely filled by the nucleus so that no cell-body is recognizable, may be 
stimulated to further growth by irritants other than that of pregnancy. 
The inflammatory changes in glandular endometritis, especially the 
form which accompanies myomata and which must be designated 
endometritis interstitialis superficialis glandularis pro- 
funda, produce alterations of the stroma in the mucous 
irHteSte'pro- membrauc, which is endowed with great proliferative 
hTthi^sTroml powers; the round, deeply staining nucleus of the stroma- 
ResembUng De- qqW bccomes larger, more' oval and less tingible, and the 

cidual Tissue. . . o ; 

cell-body, which was not recognizable, becomes quite 
distinct; the protoplasm is finely granular, although the contour of the 
cell is quite distinct. Larger cells are easily mistaken for decidual cells, 
the more so as not only the single cell, but whole columns of cells are 
seen, so that large portions of the mucosa (often the entire upper layer) 
are occupied by the altered stroma-cells. — The important differential 
point is that in pregnancy the greater portion of the mucosa is charac- 
terized by a peculiar uniformity, the decidual cells being arranged in 
regular order side by side; the mucous membrane is more translucent in 
the microscopic picture. After the cessation of pregnancy, however, a 
change soon occurs in the decidua; retrogressive processes begin and a 
positive diagnosis becomes difficult; the great vascular dilatations, 
however, are not found in glandular endometritis (see above). — Here 
again, as is so often the case in the field of microscopic diagnosis, a final 
decision will be reached by the cooperation of clinician and patholo- 
gist. — In addition to the changes which take place in the 

Stroma-cell iu ti • i i i • • i i • i i n 

Membranous stroma-cclls m glandular endometritis and which lead to 
confusion with decidual tissue, we have a similar trans- 
formation occasionally in membranous dysmenorrhea. The importance 
to the gynecologist of escaping the error of diagnosing pregnancy in a 



SPECIAL DIAGNOSIS 



197 



virgin suffering from membranous dysmenorrhea needs no comment. 
The ordinary microscopic picture of membranous dysmenorrhea, which 
is commonly seen, does not give rise to confusion: the small round cells 
of the stroma are widely separated and apparently compressed by the 
intervening exudate, the glands have a crumpled appearance (Gebhard) 
and are narrow. Even if in the deeper layers of the membrane the 
round cells of the stroma are enlarged and both nucleus and cell-body 
arc distinctly recognizable, yet the unequal size and more fibrillar char- 
acter of the intercellular substance suffice to guard against diagnostic 
errors (Fig. 98, a). But there are cases of membranous dysmenorrhea 
in which the enlarged stroma-cell, in the microscopic picture, so closely 
resembles the decidual cell that a diagnosis of pregnancy may easily be 




r' «^ 






Fig. 98. — a. Membranous Dysmenorrhea, with Crumpled (Gebhard) Glands : Interstitial exuda- 
tive endometritis. 6. Membranous dysmenorrhea with greatly enlarged stroma-cells showing decidual 
change. (Original.) 

made (Fig. 98, b; compare with the microscopic diagnosis of endome- 
tritis). By the most careful and thorough examination, taking into 
consideration all the factors — the nature of the vessels; that of the 
intercellular substance and also of the glands, although the latter are less 
important; the entirely different pictures seen in other portions of the 
mucous membrane and also by subjecting the suspected material to 
macroscopic scrutiny — a definite judgment may finally be reached. An 
examination of this kind is often exceedingly difficult because on it 
depends the decision of delicate questions; fortunately cases of this 
kind are rare. 

Although the irritation of pregnancy has certain peculiarities and 
regularly produces changes of very great extent, the irritation is never- 
theless not specific. Other irritants may produce cells resembling decid- 
ual cells ; other irritants may produce changes in the epithelium exactly 
hke the Opitz-Gebhard glands, although it should be emphasized once 



198 



GYNECOLOGICAL DL\GNOSIS 



Other Irritants 
Produce Changes 
in the Stroma 
and in the Epi- 
theUum wliieh 
Resemble those 
of Pregnancy. 



more that the epithehal changes in the uterine mucosa incident to preg- 
nancy by no means possess the same significance as the transformation 
of the stroma-cell into the decidual celL — Elements resembling decidual 
cells occur also in the absence of gestation; Opitz-Gebhard's 
glands are seen in the non-pregnant state. — The transfor- 
mation of the stroma-cell, the small round elements entirely 
filled b}^ its nucleus, into large cells resembling decidual 
cells under the influence of pathologic irritants or inflam- 
matory affections, has led to serious errors; this simple, although inter- 
esting, transformation has been mistaken for sarcomatous degeneration. 
A failure to interpret correctly the phj^siologic or pathologic cell-changes 
may lead to the adoption of incorrect methods of treatment. Points 

of importance in the differential diagnosis are 
that in the changes of pregnancy the cellular 
(decidual) transformation affects the greater 
portion of the mucous membrane uniformly, 
while a pathologic transformation is usually 
confined to the upper portion of the mucosa. 
In sarcoma, however, a more accurate exami- 
nation brings to light the atypical nature of 
the cells (larger and smaller elements) and the 
difference in the nuclei, which also take the 
stain more intensel}'; in rare instances the 
differential diagnosis between membranous 
dysmenorrhea and physiologic and pathologic 
changes (between pregnancy and endome- 
tritic alterations) may be exceedingly difficult. 
In connection with the microscopic diagnosis of pregnancy by the 
maternal tissues, i.e., the decidual cells, it is important that the examiner 
should be familiar with the change which is sometimes produced in the 
decidua by an infiammatory affection — the picture of so-called decidual 
Decidual endometritis (Fig. 99), which appears in various forms. In 

Endometritis. ^j^g acutc Variety there is marked, small-celled, inflamma- 
tion infiltration of the mucous membrane; in many portions the small 
round cells are closely packed; in microscopic sections they are usually 
intensely stained, contrasting with the decidual cells and their dehcate, 
somewhat smoky cell bodies and faintly staining nuclei. They escape 
observation altogether in a casual inspection of the microscopic prepa- 
ration, and the diagnosis of interstitial endometritis during pregnancy 
is missed. Again, the proliferation of the decidual tissue 
may produce polypoid excrescences on the surface, or bridge- 
like proliferations of the mucous membrane maj^ be formed — the 
decidua may be converted into a decidua tuberosa or polyposa. Micro- 




FiG. 99. — Decidua Vera, 
showing inflammatory infiltration 
(round-cell infiltration). 



(a) Interstitial. 



SPECIAL DIAGNOSIS 



199 



scopic examination will guard against the danger of overlooking this 
alteration, which is due to pregnancy: in this condition also a cellular 
multiplication takes place. — Finallj^, there is a more "chronic" form of 
alteration — if it be permissible to use such a word in connection with a 
condition of such comparatively short duration as pregnancy. The 
decidua, which usuallj^ represents a delicate covering of the placenta 
(decidua basilaris), or a delicate, soft, spongy, mucous membrane, is 
rigid, and the basilar portion is converted into a thick, slightly undu- 
lating, yellowish layer suggesting convolutions. This is due to changes 
in the interstitial tissue, the intercellular tissue of the mucous mem- 
brane; the decidual cells often appear smaller, are widely separated and 
forced apart by the increased intercellular substance. This change is 
usually the result of a previously existing interstitial endometritis. 
Owing to the nutritive disturbances, particularly in the decidua basil- 
aris, which it brings on, this alteration is important in the diagnosis of 





5 |<i!, it; 



Fig. 100. — Ovum from the Earliest Period: Magnified five times (7.5 mm. long, 3.0 mm. high); in the 
decidua capsularis the closure (site of implantation) is seen at i. (Original.) 



the cause of abortion. Not infreciuently these alterations are especially 
well marked in the decidua basilaris: large strands of connective 
tissue may be seen — the cellular elements are wanting over compara- 
tively large areas, or they may be increased in number by chorion-cells; 
the vessels appear in part thrombotic; here and there fatty degenera- 
tion, or even calcareous deposition, is observed; large masses of fibrin 
(fibrin-plugs) are present. Villi, enclosed in fibrin and enveloped in 
decidual and chorion-cells, may be demonstrated. All these inflammatory 
changes combine to produce a condition which may be designated 
cirrhotic decidua (vera, basilaris). 

In the interstitial inflammatory changes the epithelial constituents 
mostly play a minor part. In addition to the latter, there are also 
changes in the glandular apparatus — in fact we may speak of a gland- 
ular decidual endometritis: the glandular layer, and with it the entire 
thickness of the mucous membrane, is hypertrophied (pro- 

■..»,. Ill 11 ^^^ Glandular. 

nierated), and the latter may measure as much as 1\ cm. 

In microscopic preparations the Opitz-Gebhard glands are so densely 

packed that the appearance of malignant degeneration — malignant 



200 GYNECOLOGICAL DIAGNOSIS 

adenoma — is produced. The picture of a fungous and greatly 
hyperlrophied mucous membrane is also seen. — 

Most important for the microscopic diagnosis, especially in the dis- 
tinction between benign and malignant syncytioma, is a thorough ac- 
quaintance with the decidua basilaris. The appearance during the 
Decidua early months of pregnancy, and during the last months are 

Basiians. j-^gg-j. (^[escribecl separately. — During the first months the 

decidua basilaris — in comparison with the decidua vera (see above) — is 
irregula^r and hilly; the villi are attached everywhere and dip down into 
the superficial depressions. There is still a sufficient interval between 
the villi so that one can see between them; whereas at the end of preg- 
(a) During the naucy the villi (of the basilaris) are so closely packed that 
First Months. ^]^jg jg ^^ longer possible. In the decidua basilaris, as 
in the decidua vera, there are still found well-marked glands in the 
deeper layers, so that in the beginning a spongy layer can be recognized 
even with the unaided eye. — During the last months this plainly visible 
glandular layer disappears, and only the clefts corresponding to the 
glands are seen in microscopic preparations, besides blood-vessels. Dur- 
ing the early months there is nothing to be seen of the strip of fibrin 
which later, to a greater or less extent, occupies the superficial layer of 
the basilaris (Nitabuch). — In addition to the large, delicate decidual 
cells, other peculiar cells are very often found in the basilaris. They 
are large, often resembling the decidual cells, and traverse the basilaris 
from above downward either singly or in larger aggregations; — they 
may extend as far as the muscularis, or even beyond the boundary and 
push their way in between the muscle cells. — These cells are usually 
Chorion Cells distiuguishcd by their nuclei, which are often very large 
m the Decidua. ^^^^ sometlmcs shapclcss, taking the stain well: the cells in 
question are so-called syncytial wandering cells, i.e., fetal parts derived 
from the covering of the villi. The presence of these syncytial elements 
is the result of the attachment of the villi to the basilaris and of the 
increase of the chorionic elements; the syncytial elements grow into the 
latter (Fig. 101; compare also Fig. 91). — The attachment of the ovum 
to the basilaris is eft'ected by means of the villi in a variety of different 
ways. Until recently it was generally believed that the originally naked 
Attachment ovum, provldcd Only with small, bud-like projections which 
of Ovum. later grew into villi, attached itself to the decidua or lodged 

in a fold of the greatly hypertrophied mucous membrane; and that the 
decidua then continued to proliferate until it completely surrounded the 
ovum (capsularis) and united above the ovum, shutting off the latter 
(ovum-space) from the uterine cavity. In fact during the early stage of 
attachment, when the bed of the ovum is from 1 to 1^ cm. wide, the 
remains of the line of closure can be seen in microscopic sections (Fig. 



SPECIAL DIAGNOSIS 201 

100, at 0- -'^s the ovum grows and the vilH prohferate, the raucous 
membrane envelope of the capsularis becomes larger — the ovum, accord- 
ing to this theory, lies in a cavity lined with mucous membrane. — 
According to the most recent view (Spee in the guinea-pig, Hubert Peters 
in man), the ovum while still small passes through the epithelium of the 
uterine surface and becomes embedded in the mucous membrane; the 
viUi grow into the surrounding tissue, which becomes transformed, 
softened and filled with blood. Hence the ovum is lodged in the mucous 
membrane itself and not in a cavity lined with mucous membrane. 
The fissure which is seen in the microscopic preparation and which was 




.^:^. 



':0. 










Fig. 101. — Villus from the fourth to the fifth week, attached to the decidua basilaris by a cell-column. 
Breaking up of tlie syncytial and ectodermal covering, syncytial epithelial processes, alongside of which are 
seen villi penetrating the decidual basilaris; loss of the covering (attaching-villi). (Original.) 

formerly regarded as the remains of the closure, marks the point where 
the ovum has dipped down through the mucous membrane (site of im- 
plantation). — The proliferating villi, which at first uniformly surround 
the small ovum, become loosely attached to the surrounding tissue; 
later the villi which are destined to form the placenta (basilaris) develop 
in greater numbers at these points. — The attachment of the villi as seen 
in the basilaris during the early months may be a simple process of 
agglutination — the villus is merely applied to the surface; , , 

°" . . . ... Various Modes 

or the villus may penetrate the basilaris, leaving its epi- of viUous 

thelial covering behind on the surface of the basilaris; or, 
finally, the villus may not come in direct contact with the mucous mem- 
brane and become attached to it by a prolongation of the hood-like 



202 GYNECOLOGICAL DLIGNOSIS 

epithelial covering, which is converted into a "cell-column" (Fig. 101 
[villus to the left]). — This cell-column, which consists of syncytial con- 
stituents and ectodermal cells, instead of merely attaching itself to the 
surface, quite often shows a peculiar, spreading formation of its cellular 
elements (chorion-cells) growing into the basilaris. The syncytium 
apparently breaks up into large, syncytial elements ("syncytial" wan- 
der cells) ; the ectodermal cells multiply and fill the tissue in all direc- 
tions and, as they frequently enlarge at the same time, it 
the DeddL" may at last be difficult to distinguish them from the mater- 
cwon-ceUs. ^^^ ^^^^^ (dccidual cells) that are present. In other words, 
the attachment of the villi by cell-columns is occasionally 
accompanied by an infiltration of the maternal tissue with fetal elements. 
— A similar infiltration of the maternal tissue with ectodermosyncytial 
(chorionepithelial) elements may take place from each villus instead of 
from the cell-columns. — Epithelial proliferation may also occur in the 
villi that become attached to the surface, without the epithelial cells 
invading the maternal tissue. — The proliferation of the villous epithe- 
lium is most interesting. It occurs (1) in the growing villus during the 
early months, (2) in hydatid moles, and (3) during the attachment of 
the villi to the basilaris, and in the latter condition the chorionepithe- 
lial elements may, in addition, greatly infiltrate the maternal parts. 
If the infiltration (invasion) is very great, the suspicion of a malignant 
process may be aroused; under the influence of powerful irritants of 
unknown origin (in myoma with pregnancy, Rob. Meyer) an extensive 
and very severe infiltration of this kind with fetal elements takes place 
in the decidua and muscularis, and an inexperienced observer is very 
apt to make a mistaken diagnosis of malignant chorionepithelioma. — 
"Whether the giant-cells in the basilaris (serotina), which were described 
long ago, are merely derivatives of the epithelial covering of the villi, 
or whether non-epithelial structures of this kind occur in the basilaris 
also, is difficult to decide. It has at least been definitely observed that 
most giant-cells are derived from chorion-cells; they may represent 
large giant-cells with large, shapeless, well-staining nuclei, or giant- 
cells with numerous pale nuclei that do not stain well. During the 
later months the attachment of the villi is apparently more simple; 
besides simple agglutination of the villi with the surface — either the tip 
or part of the villous surface attaching itself to the mucous membrane — 
a number of them penetrate directly into the tissue, often to a consider- 
able depth, either vertically or approximately parallel to the surface 
(attaching-villi) ; these have no epithelium and are easily distinguished 
from the decidual maternal tissue by their stroma and paler, more 
translucent tissue (Fig. 101, villus to right). — In specimens in which the 
fetal vessels have been injected with some pigmented material, small 



SPECIAL DIAGNOSIS 203 

vessels given off by the villi and entering the decidua may be seen. 
During the later months the so-called 'septa' of the placenta in the de- 
cidua serotina demand attention: flat, columnar projections of decidual 
tissue of varying thickness — forming 'septa' — penetrate the placenta 
as far as the place where the chorionic villi originate; the villi attach 
themselves to the septa also. — 

In addition to the attachment of the villi to the basilaris, mention 
must be made of the villous proliferations in the vessels (veins), which 
occur almost regularly to a limited degree; under pathologic conditions 
the villi may proliferate far beyond the decidua and enter the maternal 
tissues (compare Fig. 86, (■)• I^i hydatid moles altered villi are seen in 
the vessels beyond the uterine muscularis. — The villi invade the basilar 
veins from the intervillous space and erode the vessels, which have no 
special walls of their own; the villi then follow the blood-stream. — 
According to the observations of some authors (Bumm, Hofmeier), 
small arterial vessels empty their contents into the intervillous space: 
and in this way — hand in hand with the veins, which often contain 
villi — an intervillous circulation is established in the human placenta. — 
(A detailed description of the intervillous space and the intervillous 
circulation, a description of the method of attachment of the ovum, 
of the changes in the uterus and its mucous membrane after expulsion 
of the fetus, and of the development of the cavity of the ovum during 
pregnancy must be sought elsewhere). — 

As has been previously stated, the microscopic diagnosis of 
pregnancy is based on the demonstration of the changes incident to 
pregnancy and of the products of gestation — on the demonstration of 
maternal and fetal tissue, the decidual cells and the chorionic 
villi. — The decidual cell is the small, round stroma-cell The Microscopic 

Diagnosis is 

of the mucosa of the uterine body altered by the irritation Based on the 

, ., . . I'll Demonstration 

01 pregnancy; and although ceils exhibitmg decidual of the Decidual 

1 1 1 1 • i 1 11 • n Cells and the 

changes and resembling these cells occur occasionally chorionic vim. 
under special circumstances, the above statement is never- 
theless in the main correct. — It has never been proven that there is a 
regular, constantly occurring transformation of the elements in any 
other situation but the mucous membrane of the body of the uterus, 
excepting the occasional occurrence in the mucous mem- 
brane of the tubes in the immediate vicinity of the ovum uarTransforma- 
(see above). — The doctrine of the transformation of the piacroniy'^fn 
cervix and its mucous membrane into decidual tissue, ,t'"' Corporeal 

' Mucosa, Never 

likewise that the upper portion of the cervix undergoes in that of 

^ "^ ^ " the Cervix. 

decidual change and is converted into a dilatation of the 

uterine cavity in order to accommodate the growing ovum, is false; 

while it is true that the cervix occasionally becomes dilated and takes 



204 



GYNECOLOGICAL DL\GNOSIS 



part in the formation of the cavity for the reception of the ovum, it 
is nevertheless always preserved as a cervix and recognizable as such. 
— Whereas, on the theorj^ of the transformation of the cervix into 
decidual tissue, the exact location of the internal os cannot be posi- 

tivel}^ demonstrated under the micro- 
scope, since the originally well-de- 
fined boundary between the cervical 
and the uterine epithelium becomes 
blurred by the transformation, it can 
on the contrary be demonstrated that 
the internal os is a fixed, immovable 
point. The proof of this is furnished 
by the fact that the mucous mem- 
brane, which becomes greatly swollen 
and transformed into decidual tissue 
during pregnane}'', remains unchanged 
in the deepest layers, that is, the part 
in contact with the muscularis (Fig. 
102) ; — in this situation the character- 
istic uterine glands can always be 
demonstrated. There are no cervical 
glands, which, if present, ought surely 
to be demonstrable in this deepest 
layer of the mucosa, if it were derived 
from the upper portion of the cervix. 
In the gravid, as well as in the non- 
gravid uterus the internal os is situ- 
ated at the boundary line between 
uterine and cervical epithelium and 
glands; it is not necessary to distin- 
guish between a histologic and an 
anatomic internal os. The decidual 
cell is the transformed stroma-cell of 
the corporeal mucosa. The demon- 
stration of this fact — that the internal 
OS is a fixed point — that no regu- 
lar, constant decidual transformation takes place in the cervix — supplies 
a firm foundation for the anatomical doctrine of the lower uterine 
^ „ . „ segment, located between the internal os and the point of 

The Cer\-ix Re- ^ > i 

cervical attachment. During the expulsion of the fetus this 
portion occasionally becomes considerably distended (drawn 
out in the longitudinal axis of the uterus), whereas the cervix takes 
part only to a very limited degree in this longitudinal distention, 




Fig. 102. — a. Position of the internal os (O.i.) 
between the fourth and the fifth months of preg- 
nancy; sharply defined boundary between cervical 
and corporeal nrucous membrane. The latter 
shows two layers: imniediately beneath the sur- 
face the mucosa exhibits decidual change, the 
deeper layer (in contact with, and in part penetrat- 
ing the muscularis) consists of unaltered uterine 
mucous membrane with unaltered uterine glands. 
b. Beginning Opitz-Gebhard change in a uterine 
gland, which lies close to the muscularis. (Original.) 



mains. Persists 
as a Cervix. 



SPECIAL DIAGNOSIS 205 

and instead undergoes principally a transverse distention, i.e., "dila- 
tation." — By means of a microscopic examination it is possible: (1) 
to decide the question whether pregnancy exists; (2) to refute the doc- 
trine of cervical transformation; (3) to explain the doctrine of the 
lower uterine segment; and at the same time to prove (4j that the 
question in regard to the internal os is not decided by the attachment 
of the ovum to the uterine mucous membrane, which is entirelj^ a mat- 
ter of accident; but that (5) the junction of the cervical and uterine 
epithelium alone determines the position of the internal os. 



Microscopic Diagnosis of the Membranes Expelled from the Genitalia, 
Especially from the Uterus. 

(Fibrin-]Membranes, Dysmenorrheic Membranes, Decidua Graviditatis.) 

Examination of the material expelled from the genitalia, especially 
from the uterus, consists in distinguishing between the material actually 
expelled and material said to be expelled, which is occasionally given the 
physician for examination. The findings of the latter, while extremely 
interesting, will not be included in the present description. — The cor- 
rect interpretation of material actually expelled from the genitalia 
may be of the greatest importance in individual cases; an error in diag- 
nosis may harm the patient and damage the physician's reputation. — 
The prognosis depends on the correct interpretation. — To make a diag- 
nosis of pregnancy, e.g., in the case of membranous d}'smenorrhea in a 
virgin, ma}' be fraught with the most serious consequences. The gravest 
errors in treatment may result if a benign condition is mistaken for 
malignancy, or degenerated myomatous material for villi. — As has 
been repeatedly emphasized, the material received for examination 
must first be subjected to careful macroscopic scrutiny. In manv 
cases an experienced gynecologist will be able to make a Macroscopic 
diagnosis without any further examination, although even inspection. 

the expert may fail to interpret the condition frem the macroscopic 
appearance alone, or may actually be led to make an erroneous diag- 
nosis. — Microscopic examination is necessary both for the Microscopic 
purpose of controlling a previously formed opinion and of Examination, 
confirming the diagnosis. — Depending on its character, material 
expelled from the genitalia, especially from the uterus, must be worked 
up in various ways. Fluid material ma}'' require chemical, 
bacteriologic or microscopic treatment, depending upon 
whether one expects to find albumin or mucin, tubercle bacilli or cocci 
(gonococci), or minute tissue elements suspended in the fluid. 



206 GYNECOLOGICAL DL4GNOSIS 

The question to be decided may be purely legal: are gonococci, sperma- 
tozoa, or particles of tumor present? — In other cases a portion of solid 
(b) Solid material may be submitted for examination. — For the 

Material. examination of fluids cover-slip preparation may suffice, 

or the fluid may require centrifugation in order to obtain cellular 
material. Dry preparations may have to be made (see above, Micro- 
^ . , , scopic Examination). — Semi-solid material, of which we 

Organized and 

Unorganized shall here consider only the membranous structures ex- 
pelled from the uterus, may be divided into two large 
groups: organized membranes expelled from the genitalia, especially 
from the uterus, and unorganized matters. 

Of the unorganized membranes expelled from the genitalia 
the most important are those consisting of fibrin, the expulsion of which 
is often attended with violent pain. Macroscopically they may closely 
resemble organized mucous membrane; under the micro- 
scope we find a network of fibrin of variable thickness, 
made up of fine fibres and small meshes, and containing numerous 
colorless blood-corpuscles, mucus-cells and epithelia, which at the first 
glance are very apt to give the impression of organized tissue. So- 
called ' canalised fibrin ' strongly suggests in its composition preparations 
of bone and bone-corpuscles with their radiating Haversian canals. — 
Next to the fibrin membranes we have blood-clots, which are also held 
together by fibrin, and depending on their age, the changes produced 
in them by the action of fluids in their immediate neighborhood, and 
also owing to their laminated arrangement, are often difficult to diag- 
nose macroscopically. If the blood is the result of a slow and scanty 
hemorrhage, especially hemorrhage into fluid, the coagula may present 
such a striking resemblance to chorionic villi or to a beginning hydatid 
mole, that a strict observance of the rule to resort to the microscopic 
confirmation is the only certain means of protection against diagnostic 
errors. Coagulated masses of mucus, of gelatinous consist- 
B[ood-ciots ency, owing to the large round cells embedded within them, 

for^viiu!' assume the most bizarre shapes by distortion, frequently 

resembling large sarcoma cells or even syncytial elements, 
and may give rise to error. Immersion in alcohol causes these masses 
to shrink and harden and, after they have been cut in sections, stained 
and washed in water, they again become glairy and gelatinous. 

The most important among the organized membranes expelled 

from the uterus are the dysmenorrheic membranes, the discharge of 

which is often attended with intense pain and in some cases 

(6) Organized. . , . ,, j i j i 

continues with great regularity tor years, the external 
appearance usually remaining practically unchanged. In other cases 
they make their appearance unexpectedly at longer or shorter inter- 



SPECIAL DIAGNOSIS 207 

vals. The membrane which is expelled in membranous dysmenorrhea is 
also called decidua menstrualis, a term which is based on an old 
erroneous conception and, as it is likely to lead to error, will not be 
used in this place. — With regard to the anatomical struc- Dysmenon-heic 
ture and microscopic composition, great differences are Membranes. 
to be noted. In the main, however, it may be said that the majority 
of observers agree with regard to the anatomical and microscopic pic- 
ture, that the typical features are only exceptionally obscured, and the 
diagnosis therefore is difficult only in exceptional cases. — The dys- 
menorrheic membranes represent portions of the uterine mucous mem- 
brane of varying size, indeed the entire upper portion of the uterine 
mucosa may be expelled. In these large pieces, eliminated in toto from 
the uterus, it is occasionally possible to recognize distinctly the region 
of the tubal orifices and that of the internal os. The thin, delicate 
membranes are usually of uniform tenuity and pale in color; they 
possess a smooth surface, corresponding to that of the uterus, and a 
slightly villous, rough surface, corresponding to the line of separation, 
or avulsion, from the uterine mucous membrane (which remains be- 
hind). — In membranes that are expelled in toto the part correspond- 
ing to the reflexion from the posterior to the anterior wall is especially 
thin. — The histologic composition of clysmenorrheic membranes corre- 
sponds to the picture of interstitial exudative endometri- 
tis; the small spheroidal stroma-cells are forced apart by Dysmenorrheic 

' ^ , 1 ./ Membranes 

the exudate; the latter appears in the preparation as a Present the 

„, iiTii- 1 Picture of 

finely granular, dust-like, often transparent mass; the interstitial 

small round cells of the stroma, however, are crowded Endometrites! 
apart and appear small and compressed. — In many prep- 
arations the framework of the intercellular substance is quite con- 
spicuous. — The glands are somewhat obscured in the microscopic 
picture; their epithelium also appears smaller, and the glands, instead of 
being straight (rectilinear), are compressed, showing zigzag forms or, 
to use Gebhard's expression, crumpled. — The tingibility is diminished 
and, as the exudate itself does not take the stain, the membranes 
appear in the picture only moderately well stained. — This picture, 
which is frequently seen and may be said to be the most common pic- 
ture of dysmenorrheic membranes, is occasionally modified by complica- 
tion with inflammatory affections of the mucous membrane and with 
hemorrhage; the stroma-cells are increased in number and accordingly 
more densely packed, the glands showing proliferation, so that the 
[above described] picture of glandular paucity and crumpled appear- 
ance of the glands is not seen; instead, the picture of endometritis 
interstitialis exudativa glandularis heemorrhagica is produced. — The 
rough external surface shows, in the microscopic picture, glands which 



208 GYNECOLOGICAL DIAGNOSIS 

are often almost completely isolated from their surroundings, and 
portions of stroma that are forced apart, but nowhere the expected 
picture of an inflammatory layer (reaction-zone). The microscopic 
picture supports the view that the membranes are mechanically sepa- 
rated by the exudative swelling which takes place in them, the sepa- 
ration being attended b}^ painful contraction of the uterus. A very 
interesting and noteworthy condition is presented by the stroma-cells 
in the deep layers, near the line of separation; whereas the stroma- 
cell of^the uterine mucous membrane is usually spherical or oval, and 
completely filled by its nucleus, certain deviations from this typical 
picture are occasionally seen. The stroma-cells in the deep layers of 
the membrane are larger than usual; in some of the cells 

Stroma-cells . ••11 ii i • t • i 

Larger in the thc protoplasm IS visible and the nucleus is distmctly 
seen within a round or oval cell. — The size of the cells 
varies; they are not closely aggregated and are surrounded by round 
cells which are completely filled by their nuclei; these enlarged and 
altered cells, which are found in the deep layers near the line of 
separation, often resemble small decidual cells. — 

The above-described condition may be regarded as the most com- 
mon in dysmenorrheic membranes; i.e., the membrane is organized 
and presents the picture of interstitial exudative stroma alteration. — 
The cells in the deep layers particularly occasionally resemble decidual 
cells. — Preparations are also encountered which, even to the unaided 
eye, present by their greater thickness and grayish-brown appearance 
certain deviations from the usual picture of dysmenorrheic membranes. 
In the microscopic picture the stroma-cells in or near the deep layers, 
or throughout the entire membrane up to the surface epithelium, are 
converted into large elements with cell bodies and nuclei. It is very 
easy to fall into the error of attributing this change to pregnancy. — 
In such cases even the experienced examiner finds it difficult to pick 
out the points of importance for a differential diagnosis. — The stroma- 
cells no longer merely resemble decidual cells but have actually 
assumed the character of decidual elements. — It is true that 
Stroma-cells in the dccidua vera, which represents an alteration clue to 

Kesemble „ . p . • i 1 i 

Decidual Cells prcguaucy, the cells are of uniform size, particularly those 

and Eventually . , . . . , . „ , . -, , ., . , 

Assume the HI adjommg portious 01 the mem^brane, while m dysmenor- 

Character of 1 . , .-, • x j. 1 • x' • • 

Decidual Cells, rlieic mcmbranes there is apt to be some variation m size. 
— The intercellular substance in the mucosa of pregnancy 
is more finely granular, often quite homogeneous, like a soft mass in 
which the cells lie embedded as though they had been pressed in; while 
in the dysmenorrheic membranes the intercellular substance is more 
fibrous, and made up of delicate fibrils. — The blood-vessels in the decidua 
are distended with blood, and lined with endothelium only, whereas in 



SPECIAL DIAGNOSIS 209 

the non-gravid state the mucosa shows thick-walled and usually rather 
narrow vessels. It is evident from what has been said that in indi- 
vidual cases the differential diagnosis between pathologic conditions 
(dysmenorrheic membranes) and changes due to pregnancy may be 
exceedingly difficult. — It is interesting to note that there are, in addi- 
tion to the irritation of pregnancy, other etiologic factors that are 
capable of producing decidual changes. — 

In addition to the dysmenorrheic membranes, true decidual 
membranes are also expelled: the microscopic examination and the 
macroscopic appearance of the decidua have already been described (see 
above). The demonstration of the decidual character of the membrane 
in itself suffices to establish a diagnosis of pregnancy; Decidual 

but it does not determine its seat, since decidual tissue is Membrane, 

formed. in the uterus in both intra-uterine and extra-uterine pregnancy. 
Histologic differences between the decidua of intra-uterine and that 
of extra-uterine pregnancy have been described : it is said that in extra- 
uterine pregnancy, in accordance with the lesser enlargement of the 
uterus, the decidual cells are smaller, the decidua as a whole thicker, 
and the glands less numerous. But the differences are not sufficiently 
characteristic, and the material submitted for examination is often too 
scanty for a thorough study, being just enough for a diagnosis of preg- 
nancy. — If chorionic villi are found among the membranous portions, 
it is a proof that the ovum is situated within the uterus. 

Occasionally cystic structures of varying size 
are discharged along with the membranous material, and of cysUc 

. • 1 1 Structures. 

also sometimes without it, but always accompanied by 
hemorrhage. The macroscopic appearance of the cysts suggests 
hydatid mole, and the provisional diagnosis is usually confirmed by 
the microscope. 

Occasionally material consisting of thick, membranous shreds of 
tissue, often tubular in shape or of irregular outline, is submitted to the 
examiner as having been expelled from the genitalia. Sometimes it is 
possible with the unaided eye to identify such material as coming from 
the vagina by the partially preserved columna rugarum; while micro- 
scopic examination, which is often quite difficult on account of the 
gangrenous change in the material, taken together with the macroscopic 
appearance, establishes the diagnosis of exfoliative vaginitis 
(particularly after some grave disease). — After severe cau- ^ , ,. . 

. . , . . . Exfoliative 

terization (chloricl of zinc) large portions of the uterine vaginitis and 

1 11 11 1 -ITT- • 1 c Endometritis. 

mucosa and muscular layer are expelled. \Vith the aid ot 
the microscope the origin of these membranous masses of varying 
thickness may be determined. But often without previous cauteriza- 
tion large "membranous" pieces may be discharged after parturition 

14 



210 GYNECOLOGICAL DIAGNOSIS 

(metritis exfoliativa), and here again the microscope must decide as to 
the origin of the suspected material. 

Besides these firm, compact masses, delicate, whitish, thin 
membranes, made up of stratified squamous vaginal epithe- 
lium, are observed. Along with the squamous epithelium 
co^^i^ttng the tips of the papillae are seen in these structures (Fig. 

EpHhSrum. 103), which represent the exfoliated superficial laver, and 

often almost the entire vaginal mucous membrane. The 
causes .of this condition are cauterization, irritation with, or local 
application of, liquor ferri chloridi, chloricl of zinc, or alum. 

Morbid products from the bladder are sometimes expelled from 
the genitalia in the shape of small, membranous particles and, owing 
to the marked proliferation of the surface epithelium, may be mistaken 






f ^ -' ■-, . . - - . 



.-.^i^:?---'*' 



W" 




■.©> 






Fig. 103. — Vaginal Membrane: Vaginal epithelium with the tips of papillae. (Original.) 

for carcinoma; but, before a diagnosis of carcinoma can be made, it 
must be demonstrated that the epithelium has slowly crept into the 
stroma; although it is quite true that papillary fibromata of the 
bladder may possess very little connective tissue. (Compare micro- 
scopic diagnosis of polypi and particles of tissue obtained from the uterus.) 
— Mycelium from the vagina (Gidium albicans) is usually expelled in 
the form of membranous shreds mixed with squamous epithelium. 

It appears, therefore, that from the genitalia, and from the uterus 
in particular, unorganized and organized products of gestation, alter- 
ations due to pregnancy, and benign and malignant masses may be 
expelled. — In most cases the nature of the material expelled can be 
positively determined by microscopic examination, or the microscope 
confirms the diagnosis based on naked-eye inspection. The question 
whether the suspected material is malignant — whether it is carcinoma, 
sarcoma, or chorionic epithelioma — cannot in most cases be decided 
without the microscope. 



SPECIAL DIAGNOSIS 211 



Displacements of the Uterus and Adjacent Organs. 

The normal uterus is movable within wide limits. Under the 
influence of abdominal pressure, and when the adjacent organs are full, 
the uterus may alter its position; but it returns to its normal position 
as soon as the cause has been removed, provided the peri- 

. . „ . ,. , , , . Definitions. 

toneum and its remiorcmg ligaments and the pelvic con- 
nective tissue possess their normal elasticity: these are physiologic 
displacements. In contradistinction to physiologic, we designate as 
pathologic displacements those which are permanent. The causes of 
these permanent displacements reside in conditions which perma- 
nently affect the uterus. Of course, even these displacements may 
correct themselves, and the uterus may return to its normal position, 
if the permanent cause is removed; thus, e.g., a uterus which has been 
displaced forward by an ovarian tumor in Douglas' space may return 
to its normal position if the tumor is removed. 

Displacements of the uterus also involve the tubes, ovaries and 
vagina; in addition, the adjacent organs, bladder and rectum, also 
suffer a change of position. As the position of the uterus usually con- 
stitutes the characteristic feature of the clinical picture, displacements 
are classified according to the position of the uterus, as follows : 

1. Positions. Displacement in which the uterus, while retain- 
ing its normal curve, varies its position in relation to the pelvis. Taking 
the pelvic axis as a basis, we speak of anteposition (anterior position — 
"the uterus is forward") when the entire uterus is dis- 
placed forward; retroposition, when the dislocation is 
backward; and lateroposition, when the organ is displaced to one side 
of the pelvic axis. In the same manner the uterus may be displaced 
upward in the pelvic axis, elevation; and downward, descent or 
prolapse of the uterus. 

2. Versions are changes in the position of the uterus in which 
the body deviates to one side of the pelvis and the cervix to the other; 
in this condition the uterus rotates around a pivotal point situated in 
the upper portion of the cervix, where it is held fast by the 

pelvic connective tissue. The version is designated with 
reference to the normal position of the uterus, and we accordingly 
speak of anteversion, when the body is displaced forward on the 
bladder; retroversion, when it turns over backward; and lateroversion, 
when it inclines to one side. In this anomaly the uterus is usually 
drawn out, elongated. 



212 GYNECOLOGICAL DIAGNOSIS 

3,. Flexion indicates a displacement of the uterine body with 
reference to the cervix and implies a change in the cervico-corporeal 
angle. We speak of anteflexion when the angle is much more acute 
than in the normal uterus, and of retroflexion when the 
body is turned over backwards so that the angle presents 
posteriorly. Lateroflexion is exceedingly rare because the uterus does 
not readily bend in this way, and most apparent lateroflexions are really 
anteflexions or retroflexions combined with torsion. 

4. T o r s i o n or rotation of the uterus around its long axis. 

Torsion. . " 

5. Inversion indicates an invagination of the uterine 

Inversion. -, . 

wall mto the uterme cavity. 

6. Hernia is a displacement of the uterus into a hernial 
sac. So far inguinal and crural hernise of the uterus are the only ones 
that have been described. 

The diagnosis of these displacements must include, besides the 
determination of the position of the uterus and adjacent organs, the 
causes of the dislocation. Most displacements are secondary and due 
to causes acting on the uterus from without. These causes in most 
cases are much more important from a pathologic standpoint than the 
displacement itself: thus, e.g., dextroposition of the uterus is in itself 
an entirely indifferent affection, while its cause, right-sided parame- 
tritis with adhesions, or a left-sided intraligamentary tumor, is the 
real source of the symptoms. This is particularly true of malpositions 
and versions of the uterus, whereas prolapse and the various forms of 
flexion are in themselves of considerable pathologic importance. 

Anteposition of the Uterus. 

The entire uterus is crowded forward: the vaginal portion is 
immediately behind the symphysis at its normal level opposite the 
lower border of the bone; the fundus is felt immediately behind the 
Palpatory abdomlual walls, and sometimes the adnexa in immediate 

Findings. connectiou with it; the vaginal vault is also displaced for- 

ward, so that the vagina runs upward behind the symphysis (Fig. 
79). Not infrequently the greatly distended bladder is found imme- 
diately behind (underneath) the abdominal walls in anteposition of 
the uterus, because evacuation of the urine is interfered with by 
compression of the urethra or of the floor of the bladder. 

The most frequent cause of anteposition of the uterus is 

Causes. . .... , . . . 

a retro-utenne tumor which, in order to gam room tor its 
development, has displaced the uterus forward. Such are tumors of 
the ovary and tube occupying Douglas' space. The most advanced 
form of anteposition occurs with large retro-uterine hematoma or 
serous or purulent pelvic exudates; the uterus is often so close to the 



SPECIAL DIAGNOSIS 213 

anterior wall of the exudate that it cannot be palpated with certainty. 
More rarel}^ the uterus is displaced forward by traction and fixed by 
adhesions; e.g., a hematoma or exudate in the vesico-uterine excava- 
tion may become inspissated, with the formation of adhesions that 
draw the uterus forward and produce permanent union with the peri- 
toneum of the anterior abdominal wall. The cicatricial tissue resulting 
from parametrial lacerations or exudates also draws the cervix, and 
with it the body of the uterus, forward. Combinations with latero- 
position occur when the tumor occupies a lateral position, or traction is 
exerted forward and to one side — with elevation, when the tumor 
develops vmderneath the uterus and pushes it upward. 

The diagnosis of this form of displacement may be difficult when 
the uterus cannot be felt with the external hand, and particularly when 
it cannot be differentiated from retro-uterine tumors by palpation. By 
making the most of the internal fingers and pushing the 

• 1 11 1 £■ 1 • 11 Diagnosis. 

anterior vagmal wall upward, enough ot the anterior wail 
of the cervix and body of the uterus may be felt to justify the assump- 
tion that the entire uterus is forward. If the bladder is distended it 
must be evacuated in order to make it possible to demonstrate the 
uterus in its forward position. 

Retroposition of the Uterus. 

In retroposition of the uterus the vaginal portion is posterior, 
while the external os is directed downward and somewhat forward ; the 
body of the uterus is in the hollow of the sacrum imme- palpatory 

diately in front of the anterior sacral wall, with the fundus Fmdmgs. 

directly under the promontory; the normal curve is preserved (Fig. 104). 

In retroposition, more than in any other displacement, the anom- 
aly itself is of no significance whatever, while the causes of the dis- 
placement are entirely responsible for the symptoms. Occasionally 
retroposition is present in the recumbent position due to 
relaxation of the ligaments, permitting the uterus to 
fall backward; this of course has no pathologic significance. It must 
be borne in mind also that the retroposition may be due to a distended 
bladder, which sometimes cannot be discovered by palpation. The 
most frequent cause of retroposition is inflammation behind the uterus 
with adhesions. The inflammation may be in Douglas' space and 
may represent the remains of an evacuated, perforated or inspissated 
hematocele or pelveoperitonitic abscess, which, in the recent stage, 
cause anterior displacement of the uterus and, as the inflammatory 
tissue contracts, draw the uterus backward and produce a retroposi- 
tion; or — what is unquestionably a more frequent cause — inflamma- 
tory adhesions are formed in the parametrium, particularly in the 



214 



GYNECOLOGICAL DLIGNOSIS 



two folds of Douglas and, by displacing the upper cervical segment 
backward and upward, produce a combination of retroposition, ante- 
flexion and elevation. A rare cause is found" in tumors situated in front 
of the uterus, lifting the uterine body from the bladder and crowding 
the entire viscus backward; thej^ are usually ovarian tumors, easily 
movable pus-tubes and, occasionally, hematomata or exudates in the 
peritoneum or in the antecervicai connective tissue. 

Combinations of retroposition and laterodisplacement are very 
frequent, when the contraction takes place in one of the folds of Douglas 




Fig. 104. — Retroposition of the Uterus from Posterior Parametritis. P.-F. }/^. (Original.) 



and draws the uterus toward that side; with retroversion, when the 
contraction acts chiefly from behind on the body of the uterus, the 
vaginal portion turning forward and the os being directed backward 
and a little downward. 

The diagnosis is easy, provided it is possible to feel the uterus 
at all. The posterior position of the vaginal portion at the pelvic wall, 
with the OS directed downward, is in itself distinctive, and may estab- 
lish the diagnosis if the abdominal walls are so thick that the uterus, 
which lies posteriori}^ and deep in the pelvis, cannot be reached. If 
the anterior vaginal vault is pushed up as far as possible and it can 



SPECIAL DIAGNOSIS 



215 



Diagnosis. 



be demonstrated that the uterus is flexed on its anterior wall, the 
diagnosis can be made with the mternal hand alone. Not infrequently 
general anesthesia is required for the diagnosis of this 
displacement. Retroposition is very frequently confounded 
with retroflexion because the two terms are used indiscriminately, and 
practitioners are in the habit of regarding every uterus that cannot be 
felt in front as a retroflexed uterus (see p. 246). 

The diagnosis of the cause is more important. Posterior 
fixation is readily recognized by drawing the uterus forward with both 
hands, or with one hand only through the posterior vaginal vault ; if 
the procedure is accompanied by pain, the cause must be sought in an 
inflammatory condition. The distinction between posterior perimetritis 




Fig. 105. — Dextroposition op the Uterus due to a Left-sided Intkaligamentart Ovarian Tumor. 
P.-F. %. (Original.) Cystic ovarian tumor, the size of an apple, in tlie left broad ligament, attached to the 
pelvic wall by adhesions posteriorly and on the left side. The uterus is completely displaced into the right half 
of the pelvis. 

and parametritis is also quite easy. If the body of the uterus is covered 
with adhesions and fixed at the point where it is covered with perito- 
neum, the cause is perimetritis; if, on the contrary, the external hand 
readily passes down behind the uterus into Douglas' space without 
feeling any adhesions, while the attempt to push up the posterior vault 
of the vagina at once meets with the resistance of resilient tissue or 
inflammatory bands, the cause is a parametritis. 



Lateroposition of the Uterus (Dextroposition, Sinistroposition). 

The uterus is displaced to the lateral wall of the pelvis and retains 
its normal flexion. The body lies on the bladder or occupies a partially 
erect position; the vaginal vault on the side toward which the uterus 
is displaced is narrowed to a mere slit by the vaginal portion, while 
on the other side the vault is well developed. The adnexa between 



216 



GYNECOLOGICAL DIAGNOSIS 



the uterus and the pelvic wall are difficult to palpate, while on the 
other side they are drawn into the middle of the pelvis (Fig. 106). 

Lateroposition in rare cases is due to congenital shortening of 
the broad ligament. Among acquired causes tumors of the adnexa, 
developing laterally between the uterus and the pelvic wall, play a 
prominent part. If the tumors are pedunculated they do 
not greatly affect the position of the uterus, and occupy 
Douglas' space or emerge from the pelvis as they grow. On the other 
hand, adherent tumors of the tube and ovary, especially intraligamen- 
tary tumors, must crowd the uterus to one side in order to gain the 
necessary space for their development (Fig. 105). Typical cases of 
lateroposition are found with intraligamentary hematomata and exu- 



Causes. 




Fig. 106. — Dextroposition of the Uterus from Right-sided Parametritis with Adhesions. 
P.-F. /^. (Original.) Tlie uterus is entirely within the right lialf of the pelvis, fixed by the inflamed and 
contracted right fold of Douglas. The left adnexa are drawn into the middle of the pelvis. 



dates. When the tumor occupies the upper portion of the broad liga- 
ment it merely displaces the uterus to one side, and lateroversion re- 
sults; when it is in the vaginal vault, a slight degree of elevation is 
often associated with the lateral displacement. In cases of bilateral 
intraligamentary tumors the uterus is caught between the two and 
forced upward. Another cause of laterodisplacement is found in 
chronic inflammation resulting in adhesions which contract and draw 
the uterus to the pelvic wall. The original exudate may have been 
intraligamentary, or may have occupied the upper portion of the 
pelvic connective tissue; or Douglas' folds on one side may contract, 
in which case the uterus also suffers a slight backward displacement 
(Fig. 106). In this way a recent intraligamentary exudate may cause 
displacement of the uterus to one side and, after absorption has taken 
place, draw the viscus through the middle of the pelvis to the opposite 



SPECIAL DIAGNOSIS 



217 



wall. Inflammatory processes resulting in adhesion are less common 
in the peritoneum and in the adnexa. 

Slight grades of lateroposition are usually overlooked. They are 
most readily recognized by marking the median line with the internal 
hand, introduced in approximately the same manner as for 

1 1 . , . , , . . , Diagnosis. 

measurmg the diagonal conjugate, and determmmg the 

relative position of the uterus. In this way it may be recognized that 

the lateral aspect of the uterus projects beyond the median line into the 




Fig. 107 



-Elevation of the Uterits from Fixation of the Organ after C^sarian Section. 

>j. (Original.) 



P.-F. 



other half of the pelvis, and that mobility in one direction is dimin- 
ished. If the lateroposition is due to a large tumor, palpation of the 
uterus may be quite difficult. Lateral fixation is recognized as the 
cause of lateroposition by attempting to bring the uterus into the 
median line, using both hands, and noting the elastic resistance 
encountered and the pain elicited by the manipulation. 

Elevation of the Uterus. 

In elevation of the uterus the organ is lifted out of the pelvis in 
the direction of the pelvic axis and brought slightly nearer the ante- 
rior abdominal wall. The vaginal portion may be found above the 



218 GYNECOLOGICAL DIAGNOSIS 

upper margin of the symphysis, while the fundus, even when the 
uterus is not enlarged, may rise almost to the navel. The uterus may 
Palpatory I'isc Spontaneously if it becomes so much enlarged that it 

Findings. j-^Q longer finds room in the pelvis (pregnancy, myomata). 

This form of elevation can be determined only by finding the vaginal 
portion at a higher level than normal and cannot be deduced from the 
level of the fundus. 

The causes of elevation are usually external to the uterus — com- 
monly'a tumor which has developed underneath the uterus and pushed 
it upward, such as hematocolpos, large carcinomata and sarcomata of 
the vagina, large submucous uterine myomata and tumors of the recto- 
vaginal septum, that have been expelled into the vagina. 
Tumors situated in Douglas' space produce anteposition 
as well as elevation. Much more rarely the uterus is drawn out of the 
pelvis by tumors attached to it by pedicles, such as ovarian tumors, or 
by adhesions attached to the anterior abdominal wall. Such adhesions 
give rise to pronounced elevation only when they have been formed at 
a time when the uterus was high up and in contact with the anterior 
abdominal wall, i.e., during pregnancy, parturition or the puerperium. 
Adhesions of this kind form after Cffisarian section or result from pyosal- 
pinx during the puerperium. They do not really elevate the uterus, 
but merely hold the organ fast in its high position and prevent it from 
sinking back into the pelvis during involution. Elevation of the uterus 
in addition results from artificial fixation, as in ventrofixation, myo- 
motomies, securing ovarian stumps with sutures, and the like (Fig. 107). 
The diagnosis of elevation is easy and presents 
difficulties only when the vaginal portion is so high as 
to be out of reach, or the uterus is so firmly adherent to tumors 
that its outlines cannot be determined. 

Prolapse. 

Prolapse is the time-honored term for downward displacement of 
the uterus and includes a number of anomalous positions of the uterus, 
vagina and adjacent organs that are etiologically quite different and 
represent entirely distinct clinical pictures. The physician 
must, therefore, never content himself with a diagnosis of 
''prolapse." He must include in his diagnosis the changes present in 
all the organs that take part in the prolapse. For this purpose system- 
atic examination of the vulva, with the floor of the perineum, and of 
the pelvis, the vagina, uterus, bladder and rectum is necessary. 

The various forms of complete prolapse represent the final stages of 
gradually developing changes, and are usually very much alike. Most 
cases of prolapse, however, that come under the physician's observation 



SPECIAL DIAGNOSIS 219 

are incomplete, or still in the process of development, and differ in ccr-- 
tain important points, until they finally reach the terminal stage which 
is practically the same in all forms. As, however, the process may 
become arrested at any stage, it is not proper to base a diagnosis exclu- 
sively on the terminal conditions; the transitional stages must also be 
described as separate and distinct clinical pictures, bearing in mind, 
however, that the transition to the final stage is often c[uite rapid. 
Thus one woman may suffer from moderate descent of the vagina 
and continue in the same condition until the end of her life, while 
in another patient a moderate degree of descent of the vagina 
(partial prolapse) may within a few months become converted into 
complete prolapse of the vagina. Similar* changes occur in the uterus. 
For this reason I have subdivided the various clinical pictures which are 
included under the generic term "prolapse." 

The various stages of development afford a good opportunity for 
investigating the mode of prolapse, and as several distinct therapeutic 
principles are based on the genesis of the condition, certain etiologic 
factors must be included in the diagnosis. Thus, treatment is materi- 
ally influenced by the question whether a prolapse of the uterus is 
primary or secondary. 

I employ the term descent for displacement of the vagina or 
uterus down to the plane of the vulva; prolapse when the parts 
descend below the vulva; and by inversion I mean invagination of 
the vagina from above through the cervix. 

The position of the patient is extremely important in making a 
diagnosis of prolapse. Theoretically the erect posture is the best, be- 
cause under the influence of abdominal pressure the displacement of 
the organs is found in the exact condition that produces the symptoms 
as the woman pursues her daily occupation. In the recumbent posi- 
tion minor grades of prolapse disappear, while the more pronounced 
forms become considerably smaller, and only a complete prolapse 
remains practically unchanged. But as examination in 
the standing posture is hardly decent, and bimanual thrwomrn 

palpation and the use of the sound are impossible, it is Ex^minaUon** 
best to examine for prolapse on the examining-chair; 
having the patient bear down or drawing the prolapsed structure as 
far out of the vulva as possible with forceps or fingers. In some cases, 
however, it is well to examine afterwards in the standing position in 
order to determine the degree of displacement present. 

The examination should be begun with inspection of the vulva. 
In minor grades of descent of the vagina and uterus the closure of the 
vulva is still almost complete; but on bearing down, the labia separate 
and the prolapsed parts come into view. In severer grades the vulva- 



220 



GYNECOLOGICAL DL\GNOSIS 



gapes to a degree corresponding to the volume of the prolapsed parts. 
In such cases the width of the introitus can only be determined by 
replacing the prolapse. Scars or perineal tears are very frequently, 
although not constantly present; even when the peritoneum 
is intact it appears greatly shortened and compressed by 
the prolapse, but the frenulum and fossa navicularis can still be brought 
out. Perineal lacerations of medium grade which have obliterated the 



Vulva. 




Fig. 108. — Anterior and Posterior Descent of the Vagina, with Descent of the Uterus. 
P.-F. 3^. (Original.) Both vaginal walls protrude as far as the introitus; moderate cystocele; small 
rectocele. Uterus somewhat prolapsed. The transverse line in these illustrations of 
prolapse indicates the plane of the vulva. 



fossa navicularis, so that the skin of the peritoneum merges directly 
with the prolapsed posterior vaginal wall, are the most common. In the 
rare cases of prolapse in nulliparae the shortened remains of the greatly 
separated hymeneal folds are seen at the introitus. The anus and the 
internal orifice of the urethra must also be inspected, because prolapse 
of the urethra and of the rectal mucous membrane is very often asso- 
ciated with prolapse of the vagina. Umbilical, inguinal and femoral 
herniffi are also fairly common. 

The vagina takes part in all varieties of prolapse, and the 
following conditions may be distinguished: 



SPECIAL DIAGNOSIS 



221 



Descent of Both Vaginal Walls. — In most cases both vaginal walls 
protrude into the introitus as the woman bears down, the anterior 
usually more than the posterior (Fig. 108) ; circular descent Descent of 

of the vaginal wall is rare. The relaxed posterior columna ■^"'posterior 
rugarum is very often obliquely placed because one side vaginai Waiis. 
has been torn away by a vaginal laceration and the columna is 
drawn over to the other side by the force of its own elasticity. 




Fig. 109. — An-teriob Vaginal Prolapse with Secondary Descent of the Uterus. P.-F. 3^. 
(Original.) Tlie anterior vaginal wall is ballooned out in front of the vulva, and contains a large cystocele 
drawing the uterus down; the posterior vaginal wall is inverted above, in situ below; no rectocele. 



Prolapse of the anterior vaginal wall causes a tumor of variable 
size in front of the vulva, consisting of the prolapsed anterior vaginal 
wall. The lateral portions of the vagina are drawn down somewhat 
by the tumor; the posterior vaginal wall in complicated 

•^ ' ■ . ^ . ° ^ . Prolapse of 

cases, so far as its lower portions are concerned, remains Anterior 

-, , . . 1-11 • • ^ !• Vaginal Wall. 

completely in situ, while the posterior vaginal vault is 
inverted by the uterus, which also descends. A cystocele is always 
present and varies in size with the degree of vaginal prolapse (Fig. 109). 
Prolapse of the posterior vaginal wall is one of the rarest forms. 
The upper third of the vagina, as far as its attachment with the peri- 
toneum of Douglas' space, may be pushed down from above, while 



GYNECOLOGICAL DIAGNOSIS 



the lower half remains in its normal position. This form of prolapse 
is most frequently observed in cases of great ascites; the uniform 
pressure of the fluid slowly forces the posterior vaginal 
wall downward until it appears in the vulva. In a similar 
manner this portion of the vaginal wall may be protruded 
by the pressure of coils of intestine occupying Douglas' space (poste- 
rior vaginal enterocele). In rare cases of infantile development congeni- 



Prolapse of 
Posterior 
Vaginal Wall. 




Fig. 110. — Phimary Isolated Prolapse of the Posterior Vaginal Wall with Large Rectocele. 
P.-F. /^. (Original.) The senile uterus, also the anterior vaginal wall, occupies the normal level. The 
posterior vaginal wall forms a large pouch in front of the vulva and contains an extensive rectocele. 

tal abnormal depth of Douglas' pouch is the cause of the descent of the 
posterior vaginal vault. Prolapse of the posterior vaginal wall usually 
affects the lower half of the structure, which protrudes into the vulva 
like a flabby pouch or transverse fold, or sometimes like a globular 
tumor, and often can be drawn down a considerable distance below the 
vulvar plane. The lateral portions of the vaginal wall usually take part 
to some extent in the prolapse, while the anterior vaginal wall remains 
completely in situ. Rectocele, or protrusion of the anterior rectal wall, 
is regularly present in cases of marked prolapse; perineal tears are 
frequently, but not always present (Fig. 110). 



SPECIAL DIAGNOSIS 



223 



In prolapse of the entire vagina the latter is entirely in front of the 
vulva (Fig. 112), and the reflexion of the mucous membrane is there- 
fore seen in the form of a complete circle immediately behind the 
introitus. Posteriorly the fossa navicularis, which belongs 
to the vestibule, of course remains in situ; the appearance 
of this fossa often gives the impression that the posterior 
vaginal wall is not completely prolapsed, but the mucous membrane is 
easily recognized as belonging to the vestibule by the absence of wrinkles 



Total 

Prolapse 

of Vagina. 




Fio 111. — Primabt Descent of the Uterus with Inversion op the Vagina. P.-F. J^. 
(Original.) Retroverted and prolapsed uterus, 7 cm. The introitus is contracted. The vagina below in 
situ and above, inverted. 



and folds (rugse). Occasionally the prolapsed vagina may present irreg- 
ular retractions produced by bands of scar-tissue connecting such points 
with the pelvic wall and fixing this portion of the vagina. In this manner 
fixation of the cervix may occasionally keep up the entire vaginal vault, 
while the lower portions lie in front of the vulva in complete prolapse. 
Inversion of the vagina, in contradistinction to prolapse of the 
vagina in which the lowest portions are always first to be displaced, 
is a circular invagination of the vagina beginning at the vaginal vault 
and, in its subsequent development, successively causing downward 
displacement of the lower portions of the canal (Fig. 111). Inversion 



224 GYNECOLOGICAL DIAGNOSIS 

is the result of a primary descent of the uterus; if the uterus drops 
from above it carries with it the vaginal vault, while the lower portions 
of the vagina either remain completely in situ or merely suffer slight 
relaxation. In severer grades of uterine prolapse the vagina becomes 
Inversion of sliorter aud shorter, until the vaginal portion appears in 
the Vagina. ^j^^ introitus. When the vagina is completely inverted it 
often lies in front of the vulva in the same way as in total primary 
prolapse. Combinations of inversion and descent of the vagina are 
frequei^tly encountered; the lower portions are relaxed and prolapsed, 
while the vaginal vault is somewhat depressed and invaginated. The 
intermediate parts may at first remain unchanged. 

The parts of the vagina that are prolapsed in front of the vulva 

and no longer covered by the mucous membrane of the introitus and 

of the labia maiora, lose their character of mucous mem- 

Secondary 

Changes in brauc, become dry and horny and assume the appearance 

the Vagina. ci-z-n- 

of skm. Owmg to the absence oi sebaceous glands they 
lose their softness and elasticity, and the surface becomes fissured and 
covered with crusts. Occasionally pigmentation takes place. 

As a result of external irritation decubital ulcers may develop on 
all the prolapsed parts, particularly the vaginal portion of the cervix. 
The ulcers are usually circular, sometimes irregular in outline or 
stellate, with a sharply defined, somewhat infiltrated border and 
BO tendency to cicatrization. The floor of the ulcers is usually covered 
with a yellovf exudate; they are soft and therefore readily distinguished 
from carcinoma. Constriction of the prolapsed parts of the introitus 
may produce edematous swelling of the mucous membrane, which 
becomes thick and glistening, and its wrinkles occasionally stand out 
in heavy ridges. In cases of chronic prolapse this leads to the develop- 
ment of hypertrophic conditions of the entire vagina. 

Diagnosis of the displacements of the vagina. The 
labia majora are separated and the patient is asked to bear down with 
moderate force; this is followed by protrusion into the introitus of a 

tumor of variable size, which is recognized as vaginal 

Diagnosis of '. , 

Displacements mucous membrane by its transverse folds. Whether 

of the Vagina. . . n • i • i i i • • 

it consists of one or both walls is determined by the position 
of the lumen of the vagina, which forms a transverse cleft, and the 
merging of the prolapse with the anterior, or the posterior commissure. 
The initial stages of prolapse of the vagina, which consist merely in 
relaxation and loosening of its attachments to neighboring structures, 
are recognized in the anterior vaginal wall by the fact that it yields 
more readily to the pressure of the finger; in the posterior, by its greater 
mobility and looser attachment to the rectum, and the ease with which 
it can be picked up in folds. A beginning inversion is recognized by 



SPECIAL DIAGNOSIS 225 

the descent of the vaginal vault. If the vagina hes entirely in front of 
the vulva, it may be difficult to decide between prolapse and inversion; 
as a rule a hint is obtained from the fact that in inversion only so much 
of the vagina is outside of the vulva as has been carried down by the 
cervix, i.e., as much as is necessary for covering the cervix and no 
more; whereas in a primary prolapse the relaxed vagina is very much 
increased both in length and in width and lies in front of the vulva 
in large folds. In primary prolapse of the posterior vaginal vault the 
ascitic collection, if present, may be discovered by a dull percussion 
note over Douglas' space, and by the ease with which the fluid can be 
pushed back; the posterior vaginal enterocele is recognized by the 
tj'mpany and by feeling the ribbon-like coils of intestine. 

After the condition of the vagina has been determined, the extent 
to which the uterus is prolapsed is investigated. In a few cases it 
is not involved in the vaginal prolapse at all and is found at its normal 
level and in correct anteversion. This condition is most 
frequently seen with a moderate descent of the lowest 
portion of the vaginal wall, and occasionally also with greater degrees 
of prolapse of the posterior wall (see Fig. 110). In the great majority of 
cases of prolapse, however, the descent of the uterus plays a most 
important part. We distinguish two different conditions. 

1. Primary Descent and Prolapse of the Uterus. — This occurs in 
conditions of relaxation of the peritoneuq;! and its ligaments and of the 
pelvic connective tissue. It is therefore regularly asso- 
ciated with retroversion, which occurs from the same Desc^nTand 
cause. The vaginal portion is in the pelvic axis below the ST uterus^ 
interspinal line. The upper portion of the vagina is in- 
verted, while the introitus and the lower segments may be normal 
(Fig. Ill); in most cases, however, the latter are also relaxed and 
displaced downward. In more severe grades of primary descent the 
vaginal portion enters the introitus, and in a fully developed total 
prolapse the uterus, covered with the completely inverted vagina, lies 
in front of the vulva, usually in retroversioflexion, rarely in anteflexion 
(Fig. 112). In a smaller number of cases the uterine prolapse is asso- 
ciated only with prolapse of the posterior vaginal wall, while the 
anterior wall merely presents a slight degree of inversion from above. 

2. Secondary Descent of the Uterus with Elongation of the Cervix. 
— This condition also is ushered in by a slight descent of the uterus with 
retroversion, due to relaxation of the peritoneal ligaments and pelvic 
connective tissue, which usually develops simultaneously with the 
relaxation of the vaginal walls. As the relaxation continues, however, 
the uterus is drawn down by the prolapsed anterior vaginal wall aided 
by a cystocele, which is connected over a wide extent with the anterior 

1.5 



226 



GYNECOLOGICAL DIAGNOSIS 



wall of the vagina and cervix. The uterus offers no resistance to the 
pull thus exerted until the vaginal portion approximately reaches the 
introitus. (In this manner secondary descent of the uterus 
is produced in primary prolapse of the anterior vaginal 
wall with cystocele, Fig. 109.) Further displacement is 
temporarily prevented by the peritoneal ligaments and 
the pelvic connective tissue, and instead the cervix is slowly dis- 
tended by the continued pull of the anterior vaginal wall and of the 



Secondary 
Descent of the 
Uterus, with 
Elongation 
of the Cervix. 




Fig. 112.- 



-ToTAL Prolapse op Vagina and Uterus. P.-F. 
large cystocle, no rectocele. 



(Original.) Uterus 7 cm.; 



cystocele; elongation of the cervix is produced. This at first, it is: 
needless to say, affects chiefly the anterior wall because it is directly 
Elongation conuectecl with the bladder; but, as the cervix represents a. 

of the Cervix. coherent mass, the elongation must — although to a slighter 
degree — cause elongation of the lateral and posterior walls also. The 
two walls of the cervix do not share equally in the elongation. In the 
anterior wall only the supravaginal portion, with which the bladder- 
is directly connected, becomes elongated; while in the posterior wall 
the elongation may affect both the supra- and infravaginal segments. 
If the infravaginal portion only is affected and there is no primary 



SPECIAL DIAGNOSIS 



227 



descent of the uterus, the posterior vaginal vault is found completely 
at its normal level (Schrdder's hypertrophia intermedia). This form 
is very rare, however, because in this case also there usually occurs 
primarily a slight descent of the uterus with inversion of the vagina. 
As a rule the reflexion of the posterior wall is found at about the middle 
of the vagina (Fig. 114), and the elongation involves the supravaginal, 




Fig. 113. — Total Prolapse of the Uterus and Vagina, with Tuberculous Ascites which Completely 
Fills the Vesico-uterine and Recto-uterine Excavations. P.-F. K. (Original.) 



and in a smaller degree the infravaginal, portions of the posterior cervical 
wall. In rarer cases the supravaginal portion only of the posterior 
cervical wall is elongated (Fig. 115). This occurs in those cases in 
which there is a primary prolapse of the lower portion of the posterior 
vaginal wall, and in which the inversion of the vagina caused by the 
descent of the uterus has continued until it coincides with the primary 
vaginal prolapse, and the entire vagina is rolled down. The entire 
posterior wall of the vagina in that case lies in front of the vulva in 



228 



GYNECOLOGICAL DIAGNOSIS 



large .folds, and the elongation of both cervical walls affects only the 
portion lying above the vagina. 

It appears, therefore, that secondary prolapse of the uterus usually 
terminates in elongation of the cervix; exceptional combinations of 
primary vaginal prolapse and primary uterine prolapse may occur. 

All the parts lying in front of the vulva may become edematous 
from circulatory disturbances and, if the latter are protracted, hj^per- 
trophic; as a result the vaginal portion becomes thickened, hard and 




Fig. 114. — -Prolapse op the Anterior Vaginal Wall with Elongation of the Cervix. P.-F. 
Y}. (Original.) Tlie anterior wall is completely prolapsed; the posterior has descended from above and is 
in situ below. The supravaginal portion of the cervix, particularly in the anterior wall, is elongated. The 
uterus 11 cm., in retroflexion. 



sometimes a little longer than normal. In nulliparas it retains its shape 
in the main, and the os, which occasionally is so small that it can barely 
be found, remains normal; in multiparse marked changes in the shape 
occur on account of the bilateral tears which are usually present. The 
two lips of the cervix, with their lateral tears, are drawn apart by the pull 
of the two prolapsed vaginal walls to such an extent that 

Secondary '^ _ ^_ ° 

Changes in a large ectropion is formed, and the external os is displaced 

the Uterus. pi i i -i i i 

to the outer surface oi the prolapse, while the lowest point 
of the prolapse is formed by the inner wall of the cervix or occasionally 
by the internal os; as a result the external os is enormously dilated. 



SPECIAL DIAGNOSIS 



229 



If there is only one lateral tear, only one ectropion is formed on the 
corresponding side and the os becomes oblique. The mucous membrane 
of the cervix which is exposed by the ectropion becomes covered with 
squamous epithelium, as do also the small mucous polyps which not 
infrequent^ develop; the epithelium remains thin, however, appears 
bluish and is easily injured. In spite of the changes in the epithelium 
the arbor vitae is still distinctly recognizable. Shallow, decubital ulcers 
are very apt to form on the inner surface of the cervix. Elongation of 




Fig. 115. — Enormous Prolapse of the Entire Vagina with Elongation of the CER\nx. P.-F. 
K. (Original.) Vagina very thick, edematous, wrinkled behind; cystocele with marked fluctuation; no 
rectocele; uterus 19.5 cm. Ectropion of the eer\-ix. 

the cervix must also be regarded as a secondary alteration; those 
portions of the elongated cervix which lie within the pelvis possess their 
normal thickness or ma.j be greatly attenuated, while the parts in front 
of the vulva become hypertrophied. 

it is not difficult to determine whether the uterus has shared 
in the prolapse. If the uterus is still within the pelvis, its position is 
determined by bimanual examination through the vagina, 

, Diagnosis of 

taking great care not to displace the organ upward. The the uterine 

points to be decided are, in the main, the level of the 
uterus, which is determined by the position of the vaginal portion with 
respect to the interspinal line, and whether the organ is normally ante- 



230 GYNECOLOGICAL DL\GNOSIS 

verted or in retroversion. If, however, the vaginal portion has descended 
as far as the introitus, the position of tlie uterus can no longer be deter- 
mined by vaginal examination, because in doing so it would be forced 
upward; in that case the position of the organ is determined by rectal 
examination, while the patient is asked to bear down or the cervix is 
drawn down with a tenaculum. If the vaginal portion protrudes far 
below the vulva, or if the entire vagina is prolapsed, the main question 
to be decided is whether one is dealing with a total uterine prolapse or 
an elongation of the cervix. This is decided by palpation and by attempt- 
ing to outline the uterus, which is covered by the prolapsed vagina. 
If the fingers can still be brought together above the fundus and in 
front of the vulva, the entire uterus is prolapsed. If, however, external 
palpation shows that part of the uterus is within the pelvis, the con- 
dition is an elongation of the cervix, and, in order to determine whether 
it extends farther into the pelvis, a rectal examination is necessary. 
The junction between the cervix and the uterine body can sometimes 
be recognized by the attachment of the folds of Douglas. If the intra- 
pelvic portion of the uterus is not elongated, the fundus can be drawn 
down in front of the vulva through the rectum, and an elongation appar- 
ently converted into total uterine prolapse. A much simpler means, 
however, of distinguishing between total uterine prolapse and elonga- 
tion is the sound. In total uterine prolapse the length of the uterus 
is found to be normal, while in elongation it may measure as much as 
20 cm. (It must be borne in mind that in prolapse, owing to the retro- 
version, the sound must be introduced with the concavity directed 
backward.) Peculiar differences in the length of the uterine canal are 
sometimes obtained with the sound; if the elongated cervix is com- 
pletely drawn out (extended) and lies partly within, and partly in front 
of the pelvis, a measurement of 12 cm. is obtained; if the uterine body 
is brought out through the rectum and placed in retroflexion, the cervix 
collapses in folds like a harmonica and, as these folds are not included 
in the measurement, the sound shows a length of 7 cm. For the same 
reason great differences may be obtained in the results of sounding 
immediately before, and after replacement of the uterus. The extent 
to which the cervix shares in the entire elongation cannot be determined 
with the sound alone because the internal os is not sufficiently well 
marked. More reliable information is often obtained by palpating 
the sacro-uterine ligaments which are attached a short distance 
below the internal os. 

The question which part of the cervix is elongated merits a careful 
study. In the anterior wall it is only the supravaginal portion that 
lengthens out; in the posterior we have several possibilities — the infra- 
vaginal portion alone, or the supravaginal portion, or both may be 



SPECIAL DIAGNOSIS 231 

elongated. The differentiation between these three conditions is made 
by the level of the vaginal vault. In the first condition it is found at 
its normal level; in the second it lies in front of the vulva just as in 
elongation of the anterior wall; while both segments must be assumed 
to be involved if the vaginal vault is found about half-way up. In 
addition the character of the elongation may be determined by the 
nature of the investing mucous membrane on the posterior surface of the 
prolapse; if the mucous membrane is smooth and without wrinkles and 
immovably attached to the cervix, the structure is the vaginal portion; 
while those segments which are covered with wrinkled, plicated, mov- 
able mucous membrane represent the supravaginal portion of the cervix. 

The floor of the bladder is almost inseparably attached to the 
upper half of the anterior vaginal wall and to the anterior cervical 
wall. For this reason the bladder is necessarily involved in all cases 
of vaginal prolapse — in some cases primarily and in rare Bladder 

cases secondarily. The shape of the viscus varies accord- ^"'^ Urethra. 
ing to the position occupied by the anterior vaginal wall and cervix. 
In every case of descent and prolapse of the anterior vaginal wall 
the lower portion of the bladder descends in front of the vulva and 
forms a sacculation, a cystocele. This is also found regularly when, 
in a primary uterine prolapse or elongation of the cervix, the posterior 
wall of the bladder descends along with the anterior cervical wall; but 
the size of the cystocele is different in the two conditions. When the 
anterior cervical wall is elongated, the attachment of the bladder to 
the cervix is lengthened by from 2 to 10 or 12 cm., and the cystocele is 
accordingly long and broad (Fig. 115); when, on the other hand, the 
uterus is primarily prolapsed, the bladder wall is merely dragged down 
to the cervix and forms a much smaller cystocele. 

Along with the bladder the posterior half of the urethra 
is displaced downward, while the anterior remains permanently 
attached to the lower border of the symphysis — the urethra 
representing a curve with the concavity directed downward as 
it courses into the bladder. The altered position of the urethra 
is readily determined with the catheter; the instrument is intro- 
duced in the usual position and the tip rotated downward. The 
bladder can occasionally be seen as an ill-defined bulging or sacculation 
behind the anterior vaginal wall or, if it contains urine, it may be de- 
monstrable as a flabby tumor, or picked up from the cervix as a thick 
fold along with the vaginal wall; the lower extremity of the bladder 
is usually indicated by a transverse furrow. The readiest means of 
recognizing the altered shape of the bladder is the catheter, with the 
aid of which the boundaries can be determined in all directions; but 
at the same time the instrument is apt to evaginate the bladder wall 



232 



GYNECOLOGICAL DL\GNOSIS 



and temporarily alter its position. In the recumbent posture the C3'sto- 
cele usually contains no urine. 

Cystoscopy affords an excellent method of examining the 
cystocele. The earliest stages of depression of the bladder wall 
may be recognized with the cystoscope as a small fold or 
pouch in the trigonum, forming the centre of the radiating folds 
of the adjacent mucous membrane. The deeper the pocket, the nearer 
will be the interureteric ligaments to the neck of the bladder; the 
ligament at the same time is curved or makes an acute angle (Fig. 
116). When the cystocele is large, the entire floor and posterior wall of 
the bladder, and with them the orifices of the ureters, are found in a 
funnel-shaped depression of the cj'stocele. By pushing the prism of 
the cystoscope forward into the cystocele and greatl}' elevating the upper 





Fig. 116. — Ctstoscopic Picture 
OF Small Cystocele, Showing the 
Interureteric Ligament Passing 
INTO IT (modified after Zangemeister). 



Fig. 117. — Cystoscopic Picture 
OF Cystocele in Front of the Vulva 
(modified after Zangemeister). 



extremity the ureteric orifices are discovered on the anterior wall. 
From this point the ureters pass in a curved direction laterally and 
upward (Zangemeister) (Fig. 117). AVith the aid of the cystoscope, 
therefore, it is not difficult to obtain an idea of the size of the c3'stocele 
and the position of the ureters. 

The lower half of the posterior vaginal wall is connected with the 
anterior wall of the rectum by loose tissue which permits a consid- 
erable degree of mobility. Hence the posterior vaginal wall may descend 
a considerable distance, or even become completely pro- 
lapsed, without necessarily dragging the rectum down with 
it. In other cases we find a marked sacculation of the anterior rectal 
wall — rectocele, which sometimes is merely a secondary effect of the 
bulging of the posterior vaginal wall. The recognition of this alteration 
in the rectum is quite easy. The finger is introduced into the rectum, 
and the position of the anterior rectal wall determined, care being taken 
not to push the wall forward and thus produce an artificial rectocele. 



Rectum. 



SPECI.\L DIAGNOSIS 233 

After the participation of all the organs in the prolapse has been 
investigated, it remains to be determined whether the prolapse can .be 
replaced, i.e., whether the vagina and uterus can be returned to their 
normal positions within the pelvis, as successful treat- „ , , , 

i _ _ ^ ... Method of 

m(>nt depends primarilv on the possibility of complete Determining 

A "i • • • 1 p 1 • Whetlier 

replacement. An anesthetic is required tor this purpose Reposition 

onl}' in exceptional cases; when the vaginal walls are very 
edematous or extremely painful, replacement is much more easily 
effected under an anesthetic. The prolapse is grasped by placing both 
thumbs against the anterior, and the remaining fingers against the pos- 
terior wall of the prolapse; and the first part of the vagina nearest the 
vulva, then the adjacent portions, and finally the vaginal portion are 
pushed back into place. After the vagina has been completely replaced, 
the uterus is turned over forward, anteverted as in retroflexion, by 
bringing the body forward and pushing the vagina backward (p. 252). 
It is of the greatest importance that the uterus be restored to its normal 
position. Moderate grades of edema of the vaginal wall, which may 
interfere with replacement, are removed by massage. The most fre- 
quent obstacles to the replacement of the uterus are found in para- 
metritic exudates, perimetritic adhesions and parauterine tumors. 
After the prolapse has been replaced, a better idea can be formed of 
the width of the introitus and the relaxation of the pelvic floor. In 
marked degrees of prolapse the introitus is wide enough to admit the 
entire hand into the vagina. 

Differential diagnosis. In prolapse, as in all other gyne- 
cologic conditions, the diagnosis must be based on the objective signs 
and not on the symptoms. The patient's statements about bearing- 
down pains and the sensation of swelling of the vulva are Differential 
by no means typical of prolapse, as the same symptoms Diagnosis, 
are sometimes complained of in vulvitis, colpitis, inflammation of the 
uterus and neighboring organs, and in some tumors; if at the same 
time a slight degree of descent is present, one is tempted to regard this 
as the cause of the symptoms and to overlook the other conditions. 

Diagnostic errors are possible even when an ol:>jective examination 
is made. Thus a cystocele protruding into the introitus may 
produce a picture very similar to that of prolapse of the vagina; such 
a cystocele, however, is usually situated to one side of the median line, 
the investing mucous membrane is greatly attenuated, the wrinkles 
are obliterated, and the contents of the cystocele appear as a bluish 
sheen in the attenuated wall. As a rule the cystocele may be recognized 
as a circumscribed, flabby, fluctuating tumor. 

Prolapse of the posterior wall may be simulated by a vaginal 
septum which has been torn from the anterior wall and protrudes from 



234 GYNECOLOGICAL DIAGNOSIS 

the introitus. The septum is usually narrow and like the keel of a boat, 
continuous only with the middle of the wall, and disappears rapidly 
above; while a prolapse is broader, involves the entire posterior wall, 
and merges above and laterall}'^ with the vagina, which is in situ. The 
presence of septal remains on the anterior wall frequently helps to clear 
up the picture. 

A complicated picture is produced in a case of total prolapse of the 
vagina when there is complete atresia of the external os, as not 
infrequently occurs in old women; the physical signs may in such a 
case resemble those of an extruded myoma or an inverted uterus. Where 
the external os cannot be found even with the smallest-sized probe and 
is not revealed by a small plug of mucus, the prolapsed vagina can still 
be recognized by this fold and by the descent of the vaginal vault. 

Prolapse is frequently confounded with elongation of the va- 
ginal portion, particularly the so-called penis-shaped hypertrophy, 
which may be so great that the external os appears at or in front of the 
vulva; or, conversely — and this is undoubtedly a still more frequent mis- 
take — the cervix in cases of descent of the uterus, when it is displaced 
downward and covered by an inverted vagina, is mistaken for an elon- 
gated vaginal portion. The points of distinction are the position of the 
vaginal vault, which in true elongation of the vaginal portion must be 
at its normal level in front and behind; the character of the mucous 
membrane covering the cervix, inasmuch as it is smooth and immov- 
able when the underljnng structure is the vaginal portion, whereas the 
presence of wrinkles and mobility indicates the beginning of a true 
vaginal nuicous membrane. 

Anteversion of the Uterus. 

Since the normal uterus lies in a position of moderate anteversion, 

the dividing line from a pathologic anteversion is not easy to define. 

We speak of a pathologic anteversion when the uterine body occupies 

a lower position than normal on the bladder, and the 

Definition and 

Palpatory vagiual portlou is displaced so far upward that the exter- 

nal OS presents directly backward or even backward and 
upward (Fig. 118); the uterus at the same time is usually fixed in this 
position. The junction of the body with the cervix, particularly in the 
presence of metritic processes, becomes rigid, and the cervico-corporeal 
angle is obliterated. 

The diagnosis of anteversion is easy. The attention of the 
examiner is at once arrested by the position of the vaginal portion, 
which may be displaced so far upward that the os can barely be reached 
with the finger; the body is in close contact with the anterior vaginal 
vault and often causes a downward bulging of that structure. 



SPECIAL DIAGNOSIS 



235 



Causes. 



It is important to search for the causes of anteversion. They 
are frequently found in a chronic metritis which has increased the 
thickness and weight of the uterus and caused it to drop forward. In 
other cases the anteversion is due to adhesions between 
the body or its adnexa, on the one hand, and the anterior 
pelvic wall on the other, drawing the uterus down and forward and 
fixing it in the abnormal position; or the cervix may be elevated and 
attached by adhesions to the posterior pelvic wall, causing the body 
of the uterus to drop forward. 




Fig. 118. — Anteversion of the Uterus. P.-F. 



(Original.) 



Definition. 



Lateroversion of the Uterus. 

The normal uterus frequently occupies a somewhat oblique posi- 
tion so that the fundus is directed toward one side and the vaginal por- 
tion toward the other, one lateral aspect presenting forward. 
The term pathologic lateroversion is used only when the 
obliquity is very pronounced or the uterus is fixed in the oblique posi- 
tion; in extreme cases the uterus may occupy a completely transverse 
position in the pelvis (Fig. 119). 

Note: Schultze applies the term lateroversion only to those displacements of the 
uterus in which the organ is rotated around its lateral surface, and includes the oblique 
positions of a normally anteverted uterus among the varieties of torsion. 



236 



GYNECOLOGICAL DIAGNOSIS 



Lateroversion of the uterus is at once suggested by the position 
of the vaginal portion when it deviates markedly to one side, and the 
OS is directed well to one side and backward; the uterine body is in the 
other half of the pelvis, with the fundus near the lateral wall. 

The causes of lateroversion may be more difhcult to discover. 

Congenital lateroversion is seen with double malformations of the 

uterus. The uterus is formed by the two ducts of Midler, 

which run obliquely from both sides downward to the 

middle of the pelvis and unite to form the single organ. 

If union fails to take place, the uterus consists of two 

oblique halves which come together at the angle. If one of the cornua 

remains rudimentary while the other reaches its full development, 



Lateroversion 
in Malforma- 
tions of 
the Uterus^ 




Fig. 119. — Sinistroveksion of the Uterus. P.-F. V}. (Original.') The uterus is almost trans- 
verse. The vaginal portion is fixed on the right side. The vaginal vault on the right side forms a cleft, on the 
left it is well developed. The left adnexa are underneath the uterus. 



there results a uterus in marked lateroversion which, however, differs 
from all other forms of lateroversion by the perfect mobility, the 
absence of adnexa at the inner side (they are given off from the 
rudimentary cornu), and usually by the median position of the cervix. 
In double malformations with fully developed cornua (uterus bicornis 
et didelphys) also, the two cornua are more or less in a position 
of lateroversion. 

As a rule lateroversion is acquired through inflammatory pro- 
cesses in the pelvic connective tissue, followed by contraction. If the 
connective tissue contained in Douglas' fold contracts, the cervix, 
Acquired ^ud with it the body, is drawn over to the pelvic wall, 

Lateroversion. bccausB the pull is exerted so high up that the body also 
is affected. But if the cicatricial contraction takes place in the deeper 
portions of the parametrium, the cervix is drawn to one side and the 
body to the other: lateroversion results (Fig. 119). This variety is 



SPECIAL DIAGNOSIS 237 

easily recognized by the fixation of the cervix and the shortening of 
the parametrium, tlie mobilitj' of tlie body being completely preserved. 
Lateroversion may also result from forces acting on the uterine body. 
An inflammatory process in the broad ligament or in the tissues sur- 
rounding the tubes, with contraction, or the short pedicle of an ovarian 
tumor may draw the body to the pelvic wall; or tumors of the adnexa 
or of the broad ligament may crowd the body to one side in order to 
gain room for their growth. As in the case of lateroposition, the tumors 
are usuall}' not pedunculated and have been prevented from growing 
upward into the abdominal cavity. A very rare cause of lateroversion 
is found in tumors which push the cervix forcibly against one pelvic 
wall and allow the body to deviate to the other side. 

Retroversion of the Uterus. 

Retroversion of the uterus represents a displacement in which the 
body deviates backward from the pelvic axis, and the vaginal portion 
is displaced forward as far as, or in front of the pelvic axis. In a diag- 
nostic sense retroversion is so closely related to retroflexion that the 
two anomalies will be treated together. 

Anteflexion of the Uterus. 

By the term anteflexion of the uterus we understand an increase 
of its normal curvature over the anterior surface; as this curvature 
fluctuates within certain limits, a slight increase over the normal angle, 
which is about 135°, must not be designated an abnor- 

,. -n-ri 1-1 r\ n ■ Definition. 

mal angulation. But u the angle is less than 90 or, m 
other words, really an acute angle, the position of the uterus is called 
a pathologic anteflexion. This does not mean, however, that abnormal 
kinking of the uterus to that extent necessarily represents a disease in 
every instance, or that it produces definite symptoms; or, if symptoms 
happen to be present, that they are necessarily to be referred to the 
abnormal angulation. On the contrary, it must be distinctly empha- 
sized that in the great majority of the cases the anteflexion is in itself 
an indifferent, and probably a secondary condition, and that the true 
cause of the symptoms, and frequently also the cause of the anteflexion, 
must be sought in the complications, such as inadequate development 
of the uterus or inflammatory conditions of the folds of Douglas. From 
this standpoint even an acute-angled anteflexion is regarded as an anom- 
aly of practically no significance. Nevertheless it cannot be omitted 
altogether from the list of uterine displacements, because in a few very 
rare cases the abnormal angulation alone must be regarded as the 
cause of the clinical symptoms. Hence in the majority of cases a diag- 
nosis of anteflexion merely indicates that the uterus is bent over for- 



238 GYNECOLOGICAL DIAGNOSIS 

ward, more sharply than normal, and docs not reach the true disease. 
In every case the physician must try to ascertain whether there are, 
in addition to the anteflexion, other conditions which must be regarded 
as the cause of the clinical manifestations. 

We, therefore, divide the diagnosis of the displacement under 
consideration into the diagnosis of anteflexion itself and the diagnosis of 
its varieties or causes. 

The diagnosis of anteflexion of the uterus is easy if a 
satisfa'ctory palpation can be made. The cervix usualty has the same 
direction as the vagina, so that the external os is directed forward and 
Diagnosis of dowuward and the body lies so close to the surface that the 
Anteflexion. finger cutcrs the angle with difficulty. If the body is felt 
through the anterior vaginal vault, the degree of anteflexion can be deter- 
mined without difficulty. Care must be exercised not to alter the angle 
during the examination; in obtuse-angled anteflexion it is very easy to 
obliterate the angle or even to bring about a retroflexion. Diagnostic 
difficulties arise only when an anteflexed uterus is displaced so far back- 
ward that the body cannot be felt by bimanual examination, or the 
cervix is so long that it cannot be reached with the internal finger, or 
the body so small that it cannot be recognized with certainty by any 
means at our command. In all such cases the uterus is thought to be 
in retroversion on account of the position of the vaginal portion or the 
elongation of the cervix, which has the same direction as 

Differential ° . ... 

Diagnosis be- the vaglna; nor is it in most cases possible to introduce 

tween Ante- ir- i ti i-i i rii 

flexion and the finger through the rectum high enough to reel the 

e reversion. anteflexion of the uterine body. Cases of this kind are 
very important in practice on account of their frequency, and because, 
if an incorrect diagnosis of retroversion is made, the patient is subjected 
to a fruitless and often very distressing course of pessary treatment. 
If in such a case anteflexion is suspected because the fundus cannot be 
certainly reached through the posterior vaginal vault, or because the 
examiner thinks he feels the anteflexion of the uterine body at the 
lateral aspect, and a positive diagnosis cannot be made, he need not 
hesitate to resort to general anesthesia. In most cases every doubt 
can be cleared up under an anesthetic. In doubtful cases the necessary 
certainty may also be attained by means of the sound, since in retro- 
version it glides into the cavity in a backward and upward direction 
as far as the ring; while in anteflexion resistance is at once encountered 
at the internal os, and the instrument can be made to glide in only by 
giving it a sharp curve or depressing the handle, or by drawing the cervix 
down with a double tenaculum. After the sound has been introduced, 
the anteposition of the fundus may be detected by feeling the knob 
through the tissues in front. 



SPECIAL DIAGNOSIS 



239 



Tumors placed in front of the uterus, such as a perimetritic exudate 
or a myoma, may be mistaken for a uterine body in anteflexion if they 
form the same angle with the cervix above the internal 
OS. The distinction can always be made by noting that 
the shape and size of the tumor are not exactly the same 
as those of the anteflexed uterine body, that exudates are 
usually more diffuse and that, on the other hand, the body of the uterus 
can always be felt or demonstrated with the sound behind the tumor. 



Differential 

Diagnosis from 

Ante-uterine 

Tumors. 




Fig. 120. — Congenital Anteflexion of the Utekus. P.-F. K. (Original.) Uterus movable; 
acute-angled anteflexion ; rigidity of the angle. Body well developed. 



In several instances I have had great diagnostic difficulties to contend 
with when the anteflexion was associated with twisting of the uterus 
due to unilateral contraction of the ligaments. The body in these cases 
was felt so distinctly alongside of the elongated cervix that I at first 
mistook it for a parauterine tumor. 

While the diagnosis of anteflexion in general is quite easy, great, 
or even insurmountable difficulties may be encountered in the effort 
to determine the variety, the etiology and the sequelae of this 
anomaly; in short, when the question whether the existing anteflexion 
is responsible for the symptoms or not is to be decided. The classical 



240 



GYNECOLOGICAL DIAGNOSIS 



symptoms of anteflexion, dysmenorrhea and sterility, are encountered 
in almost all of the varieties of the displacement and are, therefore, 
of no value for the differential diagnosis between the 
individual varieties. The most important point to deter- 
mine is whether the anteflexed uterus is freely movable or 
fixed to the posterior pelvic wall by inflammatory adhe- 
sions: this question can easily be decided by a careful bimanual exam- 
ination. If the uterus is found to be freely movable, the condition is 



Diagnosis of 
the Variety and 
Causes of the 
Anteflexion. 




Fig. 121. 



-Anteflexion of the Utekus with Fixation. P.-F. '3. (Original.) Anteflexion and retro- 
position with posterior fixation, due to posterior parametritis. 



usually congenital; the angle of anteflexion is usually rigid, unchangeable, 
and cannot be obliterated by distending the bladder. So-called rigidity 
of the angle may, therefore, be regarded as another sign of congenital 
anteflexion (Fig. 120). There is also a congenital anomaly in which a 
small, flat uterus is found at the end of an elongated cervix, movable 
backward and forward as though it were hinged, so that anteflexion 
alternates with retroflexion. The uterus in congenital varieties of ante- 
flexion is usualty small and ill-developed. Simple, movable forms of 
anteflexion may also be acquired through disturbances of nutrition in 
the uterine wall, causing; attenuation and softening of the wall and 



SPECIAL DIAGNOSIS 241 

angulation of the uterus; physiological examples of this condition are 
found in the anteflexions of the gravid and of the puerperal uterus. 

In anteflexion with fixation the uterus is in retroposition 
and moderate elevation, and fixed to the posterior pelvic wall. This 
variety of anteflexion is at once suggested by a long-drawn-out vagina, 
a high position of the vaginal portion, and posterior displacement of 
the organ (Fig. 121). Direct proof of its existence is easily found in the 
diminished or abolished mobility of the uterus forward and the pain 
which accompanies the attempt to bring it forward to the anterior 
pelvic wall. The cause of the fixation in every instance is found in the 
shortening of the two folds of Douglas (parametritis posterior retrahens) ; 
the body itself is freely movable. In anteflexion with fixation the 
altered position is always secondary and without influence on the 
symptoms, the inflammatory adhesions representing the primary 
condition and the true source of the patient's discomfort. 

The differential diagnosis between these two conditions becomes 
very difficult when inflammatory adhesions are superadded to a 
previously freely movable anteflexion. 

The congenital, rigid variety is the only one that in rare cases may 
be regarded as the direct cause of mechanical disturbances. 

Retro versioflexion . 

Retroversion is an anterior position of the uterus in which 
the body approaches the sacrum and the vaginal portion is approxi- 
mately in the pelvic axis. The uterus is usually drawn out and occa- 
sionally somewhat bent over the anterior surface. In 
retroflexion the vaginal portion is still nearer the sym- 
physis, while the body is depressed farther down and backward into 
the hollow of the sacrum and forms with the cervix an angle presenting 
backward. According to this deflnition retroversion and retroflexion 
belong to different groups, but owing to their similar etiology and the 
numerous transitions between the two that are observed, they must be 
studied together. Retroversion usually represents merely a transitional 
stage to retroflexion, and the latter develops from the former when 
relaxation in the region of the internal os is superadded. Not infre- 
quently, however, the retroversion persists either because the internal 
OS preserves its normal rigidity (retroversion in nulliparte), or because 
the uterus becomes abnormally firm through chronic inflammation of 
its walls, or fixed in a position of retroversion by inflammatory processes 
in the serous covering or in the aclnexa. 

Retroversioflexion is not a displacement of the uterine body alone; 
it involves the vagina, vaginal portion and cervix, tubes and ovaries. 
An accurate examination must include all these organs, particularly 

16 



242 



GYNECOLOGICAL DIAGNOSIS 



as many clinical symptoms are not due to a change in the position 
of the uterine body alone, but are explained by the accompanying 
changes in the neighboring organs. 

Palpation (Figs. 122, 123). — Very marked changes in the direction 
of the vagina occur. As the upper extremity of the vagina surrounds 
the vaginal portion of the cervix, it must accompany the latter in its 
forward movement; as a result the direction of the vagina, which in a 
posterior position of the vaginal portion coincides with the straight 




Fig. 122. — Retroversion of the Uterus. P.-F. Yj. (Original.) 



diameter of the pelvic outlet, runs almost vertically upward behind the 
symphysis. As the introitus also lies much nearer the anterior pelvic 
wall, the vaginal vault and the introitus approach one another much 
more closely than is the case when the vagina is straight as under nor- 
mal conditions. The vaginal tissue, being too long for the shortened 
distance, contracts if it has retained its normal elasticity, or — as may 
be observed particularly in nulliparae — the vagina is puckered and the 
folds appear in the introitus. In this way there is produced the picture 
of a descent of the anterior wall which, in contradistinction to primary 
descent of the vagina (see p. 221), is designated secondary descent 
with retroflexion. It differs from primary descent by the fact that it 



SPECIAL DIAGNOSIS 



243 



disappears completely when the uterus is replaced and the vaginal 
portion brought back to its normal position. The position of the pos- 
terior vaginal wall in its lower half is determined by its attachment to 
the rectum, while the upper half moves forward with the vaginal por- 
tion; thus an anterior flexion is produced at its middle. When the 
prolapse is associated with retroversion, the vagina becomes inverted 
from above and is thereby still more shortened. 

The vaginal portion in retroversion is displaced about as far as 




Fig. 123. — Retroflexion of the Uterus. P.-F. K- (Original.) 

the pelvic axis, while in retroflexion it is crowded still farther forward by 
the uterine body, which occupies Douglas' space. The larger the body, 
the nearer will be the vaginal portion to the symphysis; and in retro- 
flexion of the gravid uterus it is found close to the posterior wall of the 
symphysis. If the body is deep down in Douglas' space, the vaginal 
portion is drawn upward and, in retroflexion of the gravid uterus, is 
often above the upper border of the symphysis. This upward displace- 
ment of the vaginal portion causes flattening of the anterior vaginal 
vault to the extent of complete obliteration of the anterior lip, while 
the posterior lip lies in the lumen of the vagina and often appears elon- 
gated like a pig's snout, particularly as the supravaginal portion of the 



244 



GYNECOLOGICAL DL4GNOSIS 



cervix is felt through the posterior vault and therefore apt to be included 
in the vaginal portion. The dragging on the anterior wall of the vagina 
causes gaping of the cervical canal and an apparent ectropion, which, 
however, also disappears after the uterus has been replaced. The direc- 
tion of the cervical canal in retroversion forms a rectilinear prolongation 
of the uterine cavity. In moderate degrees of retroversion the external 
OS presents forward and downward; but the deeper the position of the 
uterine body, the greater will be its displacement forward, and in the 
most severe grades it is even displaced upward. In retroflexion of 

moderate degree the os presents forward 
and downward, and in acute angulation of 
the uterus more directly downward. The 
closer the vaginal portion comes to the 
anterior wall of the pelvis, the more it 
also approaches the introitus; as a result it 
is more easily reached with the palpating 
finger and therefore is thought to occupy 
a lower level. But this descent is only 
apparent; for it occupies the same pelvic 
plane as the normal vaginal portion (about 
the plane of pelvic contraction), whereas 
true downward displacement of the vaginal 
portion means a descent of the structure 
into the pelvis, as e.g., in the pelvic axis, 
such as occurs in prolapse associated with 
retroversion (Fig. 124). 

The change in the position of the 
uterine body is the essential point in 
the physical examination. "We speak of 
retroversion only when the body of the 
uterus is distinctly felt behind the pelvic axis, i.e., near the prom- 
ontory; between this position and retroflexion, in which Douglas' 
space is arched forward almost to the introitus, every possible stage 
may occur. I do not consider it practicable to subdivide 

Uterine Body. , a ■ ■ i^ • j. ■ ^ l fj-l' 

retroflexion into its various degrees, and prefer to desig- 
nate the degree of retroflexion bj^ the sacral vertebra which corresponds 
to the level of the uterus. The retroflexed body is rarely exactly 
in the median line; usually it deviates somewhat to the left, more 
rarely to the right, because retroflexion is frequently associated with 
torsion. In retroversion the posterior wall of the uterus is in complete 
extension and in rare cases it is still distinctly bent over the anterior 
surface (Schultze's retroversio cum anteflexione). In retroflexion an 
angle is formed in the region of the internal os, and this may 




Fig. 124. — Apparent and Actual 
Downward Displacement of the 
Vaginal Portion. Schematic. 'A. 
(Original.) The vaginal portion in re- 
troflexion is at the same level as that 
of the normally situated uterus, while 
in retroversion the vaginal portion is 
actually displaced downward on account 
of tlie existing descent. 



SPECIAL DIAGNOSIS 



245 



become so acute that the body lies in contact with the posterior 
wall of the cervix. 

In moderate degrees of retroposition of the body the ovaries 
retain their position at the pelvic inlet practically unchanged; if, how- 
ever, the uterine body sinks deeper into the hollow of the sacrum, 
the ovarian ligament draws the median pole of the ovary 
backward, and the gland rotates around its frontal axis, 
but in the main retains its normal position (Fig. 125). As a matter of 
fact, however, the ovaries are usually found deep down in Douglas' 
space, because the infundibulo-pelvic ligaments (suspensary ligaments 
of the ovary) take part in the general relaxation of the pelvic perito- 
neum and permit downward displacement of the ovaries. Occasionally 



Ovaries. 




Tubes. 



Fig. 12.5. — Position of the Tubes and Ovakies in Anteversion and Retroversion of the Uterus. 

Schematic, '/i. (Original.) 

the ovaries are placed so deeply in Douglas' space that they can be felt 
with the internal fingers alone on the anterior wall of the sacrum. 

An important change takes place in the position of the tubes. 
The uterine extremity is displaced forward with the fundus; while the 
abdominal end, which is attached to the ovary, remains near 
the gland (Fig. 125). In pronounced degrees of retroflexion 
the tubes run from behind forward, rendering palpation of the uterine 
extremity and therefore the diagnosis of tubal diseases extremely difficult. 

The degree of displacement of the bladder is determined by 
the position of the cervix, since it is firmly attached to that structure. 
As the cervix is displaced forward it draws the posterior wall of the bladder 
with it and produces an invagination; and in retroflexion of 
the gravid uterus, in which the cervix becomes greatly 
elevated, it carries the bladder with it so that the floor of the viscus is 
very much displaced upward and the urethra is long drawn out in length. 



Bladder. 



GYNECOLOGICAL DIAGNOSIS 

The rectum suffers invagination in cases of retroflexion partic- 
ularly when the uterus is enlarged, and a moderate narrowing of the 
rectal tube may result. 

Diagnosis. The diagnosis in retroflexions must include the 
following points: 

1. The displacement of the uterus and the secondary 
effect on the neighboring organs. 

2. It must be ascertained whether complicat ions are 
present and what relation they bear to the retroflexion. 

3. If it is contemplated to restore the uterus to its correct position, 
it must be determined whether the uterus is movable or fixed and 
what kind of fixation is present. 

The diagnosis of the displacement is based on the above- 
mentioned palpatory findings, among which the position of the body 
of course occupies the most prominent place. An inkling of the posi- 
Diagnosis of the tiou of the utcriue body may be gained from the position 
Displacement. ^j ^^iQ Vaginal portiou; if the latter is in the pelvic axis 
and the os is directed forward and downward, the uterus is usually in 
retroversion, but may also be in antefiexion. If the vaginal portion is 
anterior and the os is directed downward, the uterus is in retrofiexion 
or in anteposition. The distinction between the two positions in each 
instance can be made only by ascertaining the position of the body, 
which is most easily accomplished by bimanual palpation. But, as in 
many cases of retroflexion the examining hand is unable to reach the 
uterus when it is low down in the hollow of the sacrum on account of the 
thick abdominal walls and the intestines, it would be impossible to make 
a diagnosis in such cases were it not that the condition can also be recog- 
nized with a fair degree of certainty with the internal finger alone, 
provided, of course, the vaginal wall does not offer too much resistance 
and the uterus occupies a fairly low position. Under these circumstances 
there is felt a circumscribed resistance of the size and shape of the uterus, 
which makes an obtuse angle with the cervix; palpation of this inter- 
mediate portion is difficult when the cervix is very slender and the 
cervico-corporcal angle is acute. The retroflexed uterine body can be 
detected still better through the rectum; position, shape, consistency, 
and connection of the cervix are readily made out by palpation through 
the softer rectal wall. If this method also fails and the uterus cannot 
be reached either with the external, or with the internal hand, a cau- 
tious attempt may be made with the sound: the position of the uterus 
is recognized by the direction which the instrument assumes. In very 
difficult cases anesthesia is the last resort. I have once or twice seen 
cases in which a retroversion was overlooked or incorrectly interpreted 
because the internal fingers Were not pushed up sufficiently high through 



SPECIAL DIAGNOSIS 



247 



the posterior vaginal vault, and the external hand, placed on the ante- 
rior wall of the retroverted body, mistook that region for an anteriorly 
directed fundus. 

Differential diagnosis. The diagnosis of retroversioflexion is 
quite easy, provided the uterus can be felt. As, however, this is some- 
times difficult on a,ccount of the deep position of the body, mistakes 
are not infrequent. Among my own students the com- Differential 

monest is that a retroflexion is mistaken for a r e t r o p o s i - Diagnosis, 

tion. Aside from the fact that a number of errors have arisen from 
a confusion of the two definitions (Fig. 126) and that the pathologic 
conception of retroposition is not sufficiently familiar to practitioners, 
diagnostic errors are usually due to the fact 
that the physician promptly assumes that 
he is dealing with a retroflexion if he fails 
to find the uterine body in front in its 
normal position. This negative conclusion 
is not justified. The position of the vaginal 
portion in the posterior half of the pelvis 
alone usually is against retroflexion; and if 
the internal fingers are pushed up through 
the anterior vaginal vault, the anterior 
curve of the uterus is felt in cases of retro- 
position (the curving of the urethra over 
its anterior surface), while retroflexion may 
be assumed to be present only when the 
body can be felt or demonstrated with a 
probe in the posterior vaginal vault. fig. 126.— retroposition (black), 

T-, , • 1 i_ CI • Retroversion (blue), Retroflexion 

Retroversion and anteflexion are (red; ofthe uterus, schematic. (Orig.) 
frequently mistaken for one another, par 

ticularly in the comparatively frequent cases in which the cervix is 
elongated and the uterine body small and atrophic. The position of 
the vaginal portion is the same in both displacements, and 

. . Retroversion 

as a large part of the supravaginal cervix can frequently and 

be felt through the posterior vaginal vault, it is easily 
mistaken for the entire uterine body, particularly as the small atrophic 
uterine body cannot be positively identified in front. The best 
way to guard against this error is to feel along the lateral aspect of 
the uterus and note the anterior curve (anteflexion), or demonstrate 
the direction of the uterine cavity with the sound. 

Retro- uterine tumors may be mistaken for retroflexion of the 
uterus if they are not in close apposition with the posterior vaginal 
vault, or if they are connected at the angle with the posterior wall of the 
cervix and crowd the latter forward. Errors of this kind occur in 




248 GYNECOLOGICAL DL^GNOSIS 

cases of subserous myoma, parametritic exudates, or the remains of 
hematoceles and exudates in Douglas' pouch. The secret of differen- 
tiating between these two conditions consists in demonstrating the 
Retro-uterine positlou of the utcrus either by palpation or by the cautious 
Tumors. ^^^^^ ^^ ^|^g souud, as in the case of myomata. In cases of 

exudate and hematoma the shape and attachment of the tumors may aid 
the diagnosis; they are usually broader than the uterus; situated not 
only directly behind the cervix, like the retroflexed uterine body, but 
also tq one side; and become narrower as they approach the pelvis, 
to which they are attached. Rectal examination in these cases affords 
the most certain means of arriving at a correct diagnosis. 

Diagnosis of Complications. The objective demonstration 
of retroflexion of the uterus and the associated changes in the position of 
the adjacent organs does not suffice for a full understanding of the clinical 
Diagnosis of plcturc. lu retroflexion, more than in any other gyne- 
Comphcations. eologlc discase (see p. 70), it is necessary to ascertain whether 
the symptoms on account of which the physician is consulted can 
be attributed to the local disease or whether they possibly owe their 
origin to an entirely different affection, the retroflexion represent- 
ing merely an indifferent accessory condition. The answer to this 
question must depend on the account which the patient gives of 
her symptoms. 

The ciuestion which has to be decided most frequently is whether 
the retroflexion which has been discovered at the examination is to be 
regarded as the cause of the pains described by the patient as dragging 
sensations in the sacrum, the flanks, the abdomen and the entire back, 
as far up as the interscapular region, in the rectum in the form of pains 
accompanying defecation, during manual labor, when the patient is 
walking, or as a downward pressure, weakness, and the like. The cause 
of these painful sensations is usually found in inflammatory con- 
ditions of the adnexa, in the parametrium and perimetrium. Very 
careful combined examination is necessary to detect delicate changes 
in the adnexa, because in retroflexion they are low down in the hollow 
of the sacrum. It is still more difficult to demonstrate the presence of 
perimetritic inflammations and adhesions. An important diagnostic 
point is that in simple retroflexion cautious palpation is not attended 
with pain. Pain elicited by combined examination, whether it be by 
pressure on the vaginal portion or vagina, or by displacement of the 
uterus, should therefore suggest the existence of a complicating in- 
flammation. A positive diagnosis cannot as a rule be made until the 
uterus has been replaced. When the uterus lies in its normal position, 
it is possible to demonstrate minute changes in the adnexa as well as 
adhesions of these organs or perimetritic bands. This rule is still more 



SPECIAL DIAGNOSIS 24» 

important in the diagnosis of parametritis with adhesions (parametritis 
retrahens), which as a rule produces only painful thickening of the two 
folds of Douglas and adjoining connective tissue, and the only physical 
sign elicited by palpation is the presence of a few painful adhesions. As 
the latter are always hidden underneath the retroflexed uterus, they 
cannot be felt unless the uterus is elevated. After retroposition has 
been effected, the entire posterior parametrium can be palpated with 
certainty and, to the examiner's astonishment, the true cause of the 
pain is then discovered. This association of posterior parametritis with 
retroflexion is the most frequent cause of sacral and dorsal pains and 
the sensation of pressure in the rectum. It is only by making it a rule 
always to make a second careful bimanual examination of the tissues 
surrounding the uterus, and particularly of the parametrium, after the 
uterus has been elevated that the true cause of the symptoms can be 
recognized with certainty in every instance. These inflammatory 
changes bear a close relationship to retroflexion of the uterus, inasmuch 
as the pain is directly produced by the pressure of the uterus on the 
inflammatory adhesions. If no inflammatory conditions of any kind 
are present and the symptoms cannot be explained by some other 
abdominal disease or by a neurosis, then and only then, in the few 
remaining cases, the displacement itself may be regarded as the cause. 
In practice the greatest degree of accuracy will in general be attained 
if the physician makes it a rule not to associate abdominal pain with 
uncomplicated retroflexion of the uterus. 

With regard to the bladder symptoms also, it must be borne 
in mind that retroflexion of the uterus as such can produce them only 
when the displacement is associated with a marked distortion of the 
floor of the bladder. This is the case only when the vaginal portion is 
in immediate contact with the symphysis or greatly elevated by the 
depressed uterine body. Distortion of the floor of the bladder occurs 
only when the uterus is enlarged either by a myoma or by abnormal 
contents, and particularly in retroflexion of a gravid uterus; there is a 
very close connection between this condition and the bladder symptoms. 
In simple, uncomplicated retroflexion of the uterus there is no reason 
to assume that the displacement is responsible for the bladder symp- 
toms. Whenever there are pronounced bladder symptoms, particularly 
when there is great tenesmus, a careful examination of the centrifu- 
gated sediment of the urine and, if that proves negative, cystoscopic 
examination of the bladder must be made. If neither of these exam- 
inations gives a positive result and there is no ground for supposing that 
the frequent micturition is due to neurasthenia, as is so often the case 
in the female sex, one is justified in regarding the retroflexion as the 
cause. Such cases are extremely rare. 



250 GYNECOLOGICAL DIAGNOSIS 

The mucous membrane symptoms — vaginal discharge and 
hemorrhage — which are not infrec|uent in retroflexion of the uterus, 
are usually symptoms of a complicating catarrh due to chronic gonorrhea 
or some other bacterial infection. Menorrhagia usually finds its expla- 
nation in a complicating endometritis or in chronic atonic conditions 
of the uterus; but it may also be the result of the congestion that 
occasionally accompanies retroflexion. 

AVith regard to dysmenorrhea and sterility, it is only in 
the case of nulliparae with acute-angled retroflexion that one is justi- 
fied in assuming that the angulation at the internal os is interfering with 
conception or presenting an obstacle to the escape of the menstrual 
blood. In view of the many possible causes of these two conditions 
it is necessary to exclude all other etiologic factors before one is justified 
in attributing the disturbance to retroflexion of the uterus. 

Nervous symptoms, cephalalgia, pain in the stomach, 
respiratory neuroses and other symptoms of local and general neuroses, 
must not be attributed without further investigation to a retroflexion 
if the latter produces no local symptoms. When, however, retroflexion 
is complicated with inflammatory affections or catarrh, a direct connec- 
tion between the above symptoms and the retroflexion may occasionally 
be established. 

Special importance attaches to the complication of retroflexion 
with pregnancy — retroflexion of the gravid uterus. In the 
first two months of pregnancy it is frequently overlooked because 
enlargement and softening are not easily recognized on account of the 
extreme posterior position of the uterus, making it practically inacces- 
sible to combined examination. During the third and fourth months, 
the period when retroflexion of the gravid uterus most frecjuently comes 
under the physician's observation on account of symptoms of beginning 
incarceration that appear in the bladder, the palpatory findings become 
characteristic (Fig. 127). The flabby, cystic tumor of variable size, 
which corresponds to the greatly distended urinary bladder, first at- 
tracts attention, and it is only after the urine has been evacuated that 
the physical signs can be determined by palpation. In the vagina and 
vaginal portion the signs of pregnancy are usually quite distinct; the 
vaginal portion is in close contact with the symphysis and at a high 
level, with the os directed downward. The posterior vaginal vault is 
forced downward, in extreme cases almost to the introitus, by a uni- 
formly round tumor, which may fill the entire true pelvis. The uni- 
formly round shape of this tumor and its close apposition to the pelvic 
wall are best determined by a rectal examination. The consistenc}^ of 
the tumor is soft and, if there is incarceration, may be even tense and 
elastic. The shape and consistency of the tumor alone suggest the 



SPECIAL DIAGNOSIS 



251 



probability of a pregnant retroflexed uterus, but the diagnosis becomes 
positive only after the symmetrical junction of the vaginal portion 
with the body has been demonstrated by combined palpation through 
the posterior vaginal vault and the abdominal walls. As this junction 
is usually very soft and loose it is sometimes difficult to palpate, and one 
is apt to fall into the error of mistaking the hard cervix in front, par- 
ticularly if it is somewhat elongated, for the entire uterus, and the soft 
uterus deep clown in Douglas' space for a tumor behind the uterus. 




Fig. 127. — Retroflexion of Gravid Uterus with Greatly Distended Bladder. P.-F. ?4- (Original.) 

Hence retroflexion of a gravid uterus is most frequently mistaken for a 
retro-uterine hematocele (differential diagnosis, see p. 167), retro-uterine 
perimetritic exudates (q. v.), or a retro-uterine ovarian tumor (q. v.). 

Diagnosis of Fixation. If, after a careful study of the clini- 
cal picture as a whole, the physician arrives at the conclusion that a 
permanent correction of the retroflexion is indicated, the first thing to be 
determined is whether the uterus can be drawn into its Diagnosis of 
normal position, i.e., whether the retroflexion is movable Fixation. 

or fixed. A retroflexed uterus is called movable only when it can be 
completely anteverted and retains its anterior position for a consid- 
erable space of time, until finally it is forced over backward again, pos- 



252 GYNECOLOGICAL DL^GNOSIS 

sibly by filling of the bladder or straining at stool; it does not suffice 
for a definition of mobility that the organ can be pushed freely from side 
to side or moved about in the pelvis. The uterus is said to be fixed 
when it is so firmly attached to the pelvic wall by inflammatory prod- 
ucts of various kinds that it cannot be elevated at all or only a very 
short distance, or when the uterus, although it may be possible to bring 
it into complete anteversion, is at once drawn back as soon as it is 
released. The condition in which the uterus is merely held fast in the 
pelvic .cavity by its size (pregnancy, myoma) is called incarceration 
and not fixation. Hence, in order to make a diagnosis of fixation it is 
necessary to replace the uterus in its normal position. Reposition of 
the uterus, the main object of which is to demonstrate that the 
fixation is the result of inflammatory processes, should therefore not be 
performed in the presence of recent or very painful processes, because 
the attempt to elevate the organ maj^ increase the inflammation. 
The procedure is also contraindicated in the presence of inflamma- 
tory tubal affections, whereas in chronic parametritis and perime- 
tritis not associated with severe pain reposition should be effected 
without hesitation. 

In performing manual reposition the woman is placed in 
the coccygeo-dorsal position, after bladder and rectum have been 
completely evacuated. Two fingers are introduced into the posterior 
vaginal vault, and the uterus is elevated if possible as far as the 
Manual promoutorj', or to one side past the promontory, the 

Reposition. external hand in the mean time making deep pressure on 

the abdomen and attempting to grasp the fundus. After the external 
hand has succeeded in grasping the fundus, the internal fingers are 
changed from the posterior to the anterior vaginal vault, and the vaginal 
portion is pushed backward, while at the same time the uterine body 
is pulled down to the bladder by the external hand. Quite often the 
body drops back again at the instant when the fingers are removed 
from the posterior vaginal vault, because the external hand is unable to 
obtain a firm hold of the fundus. Sometimes, particularly if the uterus 
is very rigid, the body can be elevated indirectly by making pressure 
on the vaginal portion from the front; but even in cases of marked 
flexion it is sometimes possible to push the cervix upward and with it 
the overlying uterine body. The greatest difficulties encountered in 
reposition are the thickness of the abdominal walls and the sensi- 
tiveness of the patient. If elevation is prevented by the tension 
of the posterior vaginal vault, it may sometimes be effected 
through the rectum by introducing the index finger and elevating the 
body, while at the same time the vaginal portion is pushed backward 
with the thumb introduced into the vagina. Manual reposition requires 



SPECIAL DIAGNOSIS 253 

practice and skill, and the general practitioner, whose experience is 
generally limited, will meet with failure in many cases, and this will 
lead him to conclude that the uterus is fixed. But this is by no means 
the case. A diagnosis of fixation is justifiable only after all the various 
methods of reposition have been tried and failed. 

If after a few cautious trials it is impossible to replace the 
uterus by manual reposition, the attempt should be abandoned 
and elevation with the sound tried instead. If the instru- 
ment is used with care, no harm will be done and elevation of the uterus 
will be effected much more easily and with much less pain 

_ ^ _ ^ _ Replacement 

to the patient than by unskilful manipulation. While of t^e uterus 

with the Sound. 

abrasions of the mucous membrane and a little bleeding 
may possibly occur, I have never seen gross alterations of the paren- 
chyma or perforations of the uterine wall. The sound should have a 
flat curve and be provided with a large knob. It is introduced as 
described above into the retroflexed uterus, rotated so that the concave 
side comes in contact with the anterior uterine wall, and the handle 
strongly depressed on the perineum. By this manoeuvre a movable 
uterus is elevated sufficiently so that it can be grasped from the out- 
side with the (right) hand and drawn down to the bladder, while with 
the (left) hand the sound is held in place within the uterus. After the 
uterus has been drawn forward, the vaginal portion is pushed back 
with the two internal fingers, and the sound withdrawn. If the uterus 
is fixed, elevation is almost or cjuite impossible, and the attempt at 
reposition causes pain by pulling on the adhesions. Short tense adhesions 
are recognized by the resilient character of the resistance encoun- 
tered by the sound during reposition. In those cases in which the 
sound, as it is held in the fingers, continually tends to rotate so that the 
concavity of the instrument presents backward or, in other words, tends 
to return to the position of retroflexion, it may be assumed as very 
probable that the uterus is fixed. 

Instead of using the sound, reposition can also be effected in the 
following manner: The anterior lip is seized with a Muzeux tenaculum 
and forcibly drawn forward and downward; at the same 
time the body is elevated as far as possible either with the by Trartton 
index finger of the left hand introduced into the rectum "^TenSum"! 
or with two fingers in the posterior vaginal vault; the 
vaginal portion is then pushed backward with the tenaculum, the 
handle of which is elevated toward the woman's abdomen. Occasion- 
ally replacement can be effected by this method with remarkable 
ease (Kiistner). 

If the use of the sound is contraindicated or the procedure fails for 
technical reasons, e.g., in nulliparae, manual reposition can be effected 



254 GYNECOLOGICAL DIAGNOSIS 

under general anesthesia. This is undoubtedly the least harmful 
method to the genitalia and, in addition, offers the best possible 
means of detecting adhesions by direct palpation. 

It is not enough merely to determine that fixation is 

theK^'d'of present; one must also investigate the character of 

PresenT ^^^ fixatlou. Fiom the standpoint of treatment 

this is the most important part of the diagnosis. The 

following varieties of fixation are distinguished: 

1: Intraperitoneal or perimetritic fixation. In this 
form the fixation is due to peritonitic adhesions which may develop 
wherever the uterus is covered with peritoneum. They are found most 
Perimetritic frequently on the posterior wall, as far up as the 
Fixation. fuudus, or ou the lateral aspect near the diseased adnexa, 

in which these inflammatory processes usually have their beginning. 
The adhesions may consist of solitary bands or flat membranes of 
varying length. Sometimes a perimetritic adhesion, if associated 
with contraction and obliteration of the peritoneum, or if it 
represents the remains of an inspissated hematocele or exudate, may 
cement the uterus so firmly to the pelvic wall that the organ is abso- 
lutely immovable. In most cases, however, the adhesions consist of 
solitary bands and membranes, which still permit a certain degree of 
mobility and not infreciuently allow the uterus to be completely 
replaced. Their perimetritic character is recognized by the fact that 
they are attached to those parts of the uterus which are covered with 
peritoneum, and by their irregularity and great tenuity, so that they 
often tear at the lightest touch. 

2. Parametritic fixation may lead to permanent retro- 
versioflexion in two ways: either by a firm attachment of the 
cervix to the anterior wall of the pelvis, in the form of contracting 
Parametritic exudatcs of the auterior parametrium or bands of cicatricial 
Fixation. tissuc, the remains of lacerations; or fixation may occur at 

the posterior pelvic wall, if a pull is exerted on the body from behind. 
The adhesions resulting from old exudates in the posterior portion of 
the broad ligament, or underneath the detachable part of the perito- 
neum, attach themselves so high up on the body that a backward pull 
is exerted principally on this portion of the uterus. Occasionally the 
contracted folds of Douglas alone may produce a permanent retro- 
version, if they are attached unusually high on the posterior wall of the 
uterus; this is observed with special frequency in nulliparae. Large 
parametritic exudates developing during an existing retroversion 
also lead to fixation. The diagnosis of parametritic fixation rests on the 
demonstration of an exudate or solitary bands of adhesions somewhere 
in the connective tissue surrounding the uterus, while the organ itself, 



SPECIAL DIAGNOSIS 255 

wherever it is covered with peritoneum, and the entire space of Douglas, 
are free from adhesions. Parametritic adhesions are mucli tliicker 
and firmer than perimetritic bands. 

3. Indirect fixation from disease of the adnexa is 
quite frequently observed. The adnexa become adherent to the pos- 
terior pelvic wall and hold the uterus fast on both sides, , . 

, , , . Indirect Fixa- 

while the uterine body itself is not necessarily fixed. The tion by dis- 

«,. . „«.., , ,, eased Adnexa. 

diagnosis or this variety or fixation is based on the dem- 
onstration of adherent tumors of the adnexa, which often have such 
a broad connection with the body that it is difficult to differentiate 
between the two structures. 

A rare cause of permanent displacement of the uterus is abnor- 
mal shortness of the anterior vaginal wall, as a result of 
which the vaginal portion is fixed near the anterior pelvic wall and 
the uterus thereby brought into a permanent position of 
retroversion. The attempt to push the vaginal portion shortaesrof 
back for the purpose of replacing the uterus is only par- vagintrwa°u 
tially successful and the structure comes forward again 
as soon as it is released. This primary shortening of the anterior vaginal 
wall may be congenital or due to senile shrinking. It must not be con- 
founded with secondary shortening, which is produced in retroversion 
of the uterus by elastic contraction of the anterior wall; in the latter 
case the uterus can usually be replaced. 

Torsion of the Uterus. 

Torsion is rotation of the uterus around its long axis. It may 
occur either in the vagina, causing rotation of the entire uterus around 
its axis, or in the substance of the uterus itself, either in the region 
of the internal os or above the os, in the body; in the latter case 
the lower segment of the uterus remains in place and the body alone 
becomes twisted. 

Torsion occurs most frequently in connection with anteflexion and 
is due to contraction of the folds of Douglas on one side, drawing one of 
the lateral aspects of the uterus backv/ard. In a similar manner the 
uterine body in retroflexions is found displaced to one side, usually 
the left, as a result of torsion, and not directly backward. In uterus 
bicornis the organ is usually twisted so that one cornu is directed 
forward and the other backward. The diagnosis of these torsions, 
which always affect the entire uterus, is based on finding that the 
surfaces of the organ, instead of presenting exactly forward and 
backward, have a slight lateral deviation. On inspection with the 
speculum the external os is frequently found to be obUque or even 
in the sagittal plane. 



256 



GYNECOLOGICAL DIAGNOSIS 



Torsion in the substance of the uterus itself is produced by the growth 
of subserous myomata, or ovarian tumors with short pedicles. The diag- 
nosis is never made unless it be by accident, usually from the position 
of the adnexa. In most cases it is made by inspection during operation. 

Inversion of the Uterus. 

From a gynecological standpoint we are interested in two varieties 
of inversion, — chronic puerperal inversion and inversion of the uterus 
by tumors. 



ii*l| 



>p^^^ 




f n 




Fig. 128. — Total Inversion of the Uterus from the Birth (Exp^tlsion) of a SuBiancous Pedun- 
culated Myoma. .'i. (Original.) The uterus and the submucous myoma are gangrenous; on the left 
a tubal orifice is visible. 

In chronic puerperal inversion the wall of the uterine body 

at the fundus is invaginated into the cavity. The inverted portion 

may extend only to the internal os; or the inverted uterine body may 

protrude into the cervix, or through the latter into the 

Chronic . . . 

Puerperal vaglua; or the cervix — at least its upper segment — also 

Inversion. ... . ,^, . „ , , 

takes part in the inversion. I he region oi the external os 
is usually not affected. The invagination produces above an inverted 
funnel of variable depth, which receives the adnexa of both sides. 
On vaginal examination of the inverted uterus a soft, polypoid body 
is found, conical above and disappearing in the external os. By intro- 



SPECIAL DIAGNOSIS 257 

ducing the finger into the external os tire junction between the inverted 
and unaffected portion of the cervix can be demonstrated around the 
entire periphery; this reflexion-fold above the external, os may often 
be made to disappear by drawing the. inverted uterus downward and 
thus completing the inversion of the cervix. If the junction of the 
inverted uterus with the cervix cannot be positively recognized with 
the finger, it may be demonstrated with the sound, which meets with 
the resistance of the inverted cervix at every point on the neck of the 
polyp and nowhere enters the uterine cavity. Some characteristic 
points are also observed on inspection with the speculum: the surface 
is smooth, velvety, glistening and intensely red; occasionally the two 
tubal orifices may be seen as small retractions at the lower extremity 
of the tumor. 

Although in favorable cases inversion of the uterus can be recog- 
nized in this way by vaginal examination alone, so much depends 
upon the diagnosis that an accurate bimanual examination should 
always be made, preferably through the rectum and abdominal walls. 
The absence of the uterine body can at least be demonstrated without 
any difficulty by this method, and if the abdominal walls are not too 
rigid, it is possible to recognize the inversion at the site of the missing 
uterus as a distinct fossa or depression which receives the extremities 
of the tubes, while the ovaries are usually found at the edge. 

Differential diagnosis. The only condition with which 
inversion of the uterus may be confounded is a submucous uterine 
myoma lying in the vagina (for the differential points between the two 
see p. 282). 

The diagnosis of inversion in the presence of a uterine 
tumor can be made only if the myoma along with the inverted 
uterus lies in front of the vulva. If the tumor is attached by a pedicle 
to the inverted uterine wall, the two can be distinctly inversion 

differentiated by feeling a constriction or a ring (Fig. 128); with Tumors, 
but if the tumor is attached to the uterus by a broad base, the two 
structures merge into one another, and it is occasionally possible to 
differentiate them only by detecting a distinct difference in consistency, 
the uterine body being softer than the myoma. In these cases also an 
attempt should be made by combined examination through the 
abdominal walls to demonstrate an inversion-funnel; if the uterine 
wall is only partially inverted by the tumor, the examination is, 
however, not likely to prove successful. 

Andruszat found that among 4.5 cases of total inversion due to myoma, only 2 were 
not recognized before operation; while in 9 out of 15 cases of partial inversion no clinical 
diagnosis was made. 

17 



258 GYNECOLOGICAL DIAGNOSIS 



Diagnosis of Uterine Myomata. 

The diagnosis of myoma presupposes a familiarity with the topog- 
rapliy of the various developmental forms of this tumor, and of at 
least equal importance is a knowledge of the peculiarities which the 
tumor presents on palpation and which are due to its anatomical struct- 
ure. ' For this reason I shall first give a description of the topography 
and special features of myomata, before discussing the diagnostic 
principles on which the recognition of these tumors is based. 

Topography of Myomata. 

Uterine myomata are circumscribed neoplasms of the uterine 
muscle; they usually begin as multiple tumors, but only a limited 
number of them undergo further development. In most cases there is 
Topography o^e large myoma with a few smaller ones grouped around 
of Myomata. ^^^ usually sltuatcd witliiu the capsule of the large tumor. 
In other cases there may be a conglomeration of myomata grouped 
around the uterus; absolutely solitary myomata are rare. All myo- 
mata are primarily interstitial; but owing to the various directions 
in which the tumors grow, a number of clinically and anatomically 
distinct varieties are produced. 

In the uterine body we distinguish the following: 

L Subserous myomata. A myoma is called subserous when it 
grows out of the outer wall of the uterus at a point which is covered 
with serous membrane. The difference between subserous and inter- 
Subserous stitial myomata is that in the former the greater portion 

Myomata. ^f ^^iQ clrcuuif creucc of the tumor is outside of the uterine 

wall and has no thick mantle of uterine muscle (Figs. 129 and 130). 
Small myomata produce a nodular thickening on the outer surface of 
the uterus; the larger ones are independent tumors, with a more or 
less broad surface of attachment to the uterine wall. As a subserous 
myoma increases in size it grows farther and farther away from the 
uterine wall, to which it is attached only by a pedicle. If the pedicle 
is very broad it is usually formed b}^ part of the myoma; smaller pedi- 
cles contain only muscle tissue; a very small pedicle may occasionally 
be composed of nothing but peritoneum and blood-vessels ; complete 
detachment of the pedicle occasionally occurs. 

When a subserous myoma grows from the lateral aspect of the uterus 
it gets in between the t\Vo layers of the broad ligament and is called 
an intraligamentary myoma. This variety may also become 
entirel}^ detached from the uterus and occupy the broad ligament as an 



SPECIAL DIAGNOSIS 



259 



isolated tumor. When a subserous myoma originates in the lower por- 
tion of the uterine bod)'', where it is covered with loosely attached 
peritoneum, it elevates the peritoneum and continues to grow under- 
neath the membrane. This variety is called subperitoneal, in 
contradistinction to subserous myoma. Posteriorly such tumors may 
elevate the peritoneum lining Douglas' space and the posterior wall 
of the pelvis, coming in contact with the posterior wall; in front they 
get underneath the peritoneal lining of the vesico-uterine excavation and 
displace the bladder. My- 
omata originating more in 



the lateral portions of the 
anterior and posterior 
walls get into the broad 
ligament underneath the 
cecum and sigmoid flex- 
ure. When the pedicle is 
thin, the uterus retains its 
shape except at the point 
where the pedicle is at- 
tached; the organ is, how- 
ever, generally somewhat 
elongated and thickened 
from muscular hypertro- 
phy. The cavity is altered 
only when part of the 
myoma still occupies the 
wall; in pedunculated tu- 
mors it is merely some- 
what elongated according 
to the lengthening of the 
entire uterus (Fig. 147). 
2. Interstitial (intra- 
parietal, intramural) myo= 
mata still occupy the wall of the uterus, are everywhere surrounded by a 
mantle of uterine muscle and project only a little beyond the outline of the 
organ; they cause enlargement in all dimensions of the wall which they 
occupy, while the sound wall is distended both in length and breadth and 
often considerably diminished in thickness. Interstitial myomata cause a 
general enlargement of the uterus which may be as uniform interstitial 

as that of the gravid uterus (Fig. 131), although as a rule Myomata. 

the affected wall bulges somewhat. Owing to the hypertrophy of the 
muscular tissue surrounding the myoma the external contours of the 
tumor are somewhat rounded. The uterine cavity undergoes many 



I 




Fig. 129. — One Subserous and Two Interstitial Myo- 
mata OF THE Uterus. %. (Original.) (From a specimen in 
the Kgl. Universitats-Frauenklinik in Berlin.) 



260 



GYNECOLOGICAL DL\GNOSIS 



changes in interstitial mj^oma. The distention on the side of the 
myoma causes a marked increase in the length and width of the 
affected wall. The cavity is very much displaced eccentrically, being 
very close to one wall of the uterus and separated from the other by 
the entire thickness of the myoma. If the tumor projects into the 
cavity, the latter becomes somewhat curved (Fig. 147). 

3. Submucous myomata are tumors which grow toward the uterine 
cavity so that about one-half their circumference projects into it. The 

_ inner surface is covered 

only with mucous mem- 
brane or at the most with 
a very thin mantle of 
muscle tissue (Fig. 132). 
In the course of their 
growth they encroach still 
further on the uterine 
cavity and produce a uni- 
form distention of the 
uterus so that the shape 
sometimes becomes en- 
tirely spherical. The uter- 
ine wall becomes uniformly 
thin except at the base of 
the tumor. The extent 
of the attachment to the 
uterine wall is very vari- 
able; when it is broad, it 
is formed by the myoma 
itself; smaller attach- 
ments consist entirely of 
muscular tissue. The 
greatest changes produced 
by submucous myomata are found in the cavity, which becomes longer, 
broader and, in the case of myomata with slender pedicles, completely 
surrounds the tumor, which lies almost free in the cavity (Fig. 147). 
By pressure on the inner surface of the uterus and on the internal 
OS submucous myomata excite reflex uterine contractions, which may 
produce considerable changes in the position of the tumor. The internal 
Birth of OS dilates, and the top of the tumor enters and dilates the 

a Myoma. ccrvlx: tlic tumor then reaches the external os, which it 

also dilates even to the extent of complete obliteration, and enters the 
vagina. Here the tumors are usually arrested or occasionally, under 
the influence of vigorous abdominal pressure, may be forced down in 




Fig. 130. — The Same in Sagittal Section-. 



(Original.) 



SPECIAL DIAGNOSIS 



261 



front of the vulva. This change of position — the birth of the myoma — 
is possible onlj^ if the pedicle becomes greatly distended. These myo- 
mata are called fibrous polyps (Fig. 134). The birth of a broadly 
sessile myoma is followed by partial inversion of that portion of the 
uterine wall in which the myoma originates. The great stretching 
of the pedicles, which contain the nutrient vessels, leads to anemic 
necrosis and, with the cooperation of the vaginal micro-organisms, to 
complete disintegration of the tumor. 

In all varieties of myoma, and most frequently in the submucous 
and interstitial, the mucous membrane of the uterine body is in a con- 
dition of extreme in- 
flammatory thickening 
showing the type of 
glandular and intersti- 
tial endometritis. 

Cervical Myomata. 
This variety is much 
more rare. Most of the 
myomata found in the 
cervix have their origin 
partly in the body and 
partl}^ in the cervix, or 
they begin in the body 
and slowly grow into 
the cervical wall. Pure 
cervical myomata are 
rarely seen; thej^ are 
also subdivided into the 
three varieties which 
are described above. 

Subserous cervical myomata in the narrow sense of the 
term do not occur, as the cervix is nowhere covered by firmly adherent 
serous membrane. Myomata originating in the outer surface of the 
cervix always become subperitoneal or intraligamentary, are always 
surrounded by pelvic connective tissue, and covered with peritoneum 
only on their upper surface. They displace the adjacent organs (ureter, 
bladder, rectum) and push the body of the uterus upward to a position 
at the upper pole of the tumor (Fig. 135). 

Interstitial cervical myomata (Fig. 136) distend the wall 
in which they are lodged in all directions, while the opposite wall 
becomes greatly attenuated, drawn out, and surrounds the affected wall 
in the form of a crescent. As a result the external os is greatly 
distended in the transverse direction. 




Fig. 131. — Interstitial Myoma of the Posterior Wall. %. 
(Original.) (From a specimen in the Kgl. Universitats-Frauen- 
klinik in Berlin.) 



262 



GYNECOLOGICAL DIAGNOSIS 



.Submucous my o mat a which grow toward the cervical canal 
early become pedunculated and make their appearance in the external 
OS in the form of fibrous polyps; those which develop in the vaginal 
portion grow toward the vagina (Fig. 137). 

Combinations of several myomata belonging to different forms 
are frequently seen: subserous, interstitial, submucous, corporeal and 
cervical myomata develop side by side. Every myoma exhibits the above 
described changes, and the picture as a whole may be very complicated. 




Palpatory Properties of Myomata. 

These are properties which myomata present on palpation as a 
result of their anatomical structure and their connection with the 

parent organ. I shall here discuss 
onh^ those changes which are of real 
value for the clinical diagnosis. 

Shape. Myomata are round, 
rarely oval and, as their growth is 
concentric, they in the main retain 
this shape. The true myoma shape 
is least conspicuous in the interstitial 
variety because the tumor is entirely 
surrounded by a mantle of muscle 
tissue. The typical spherical shape, 
with smooth surface, is best seen 
in subserous myomata; but these 
again present most variations from 
the typical form because they not 
infrequently develop the characters 
of an independent tumor. In that 
case they become oval, lobulated and divided into large segments, and 
the surface is not infrequently mammillated or nodular. Submucous 
myomata are also spherical in shape so long as they are within the 
uterus; but under the influence of the uterine contraction 
when expulsion begins, some remarkable changes in shape 
are produced; the tumors are drawn out in length and adapt them- 
selves to the shape of the uterine and cervical cavities, frequently 
exhibit constrictions produced by the os, and become long and thin 
like polyps. Subserous myomata undergo a remarkable change of shape 
during pregnancy; they are drawn out in a transverse direction by the 
distention of the uterus and, instead of forming a round protuberance, 
merely represent a flat thickening of the uterine wall. 

Consistency. From a diagnostic standpoint this is unquestionabl}^ 
the most important property of myomata. It depends on the compo- 



FiG. 132. — SuBMUcot's Myoma in the Cav- 
ity OP THE Uterine Body. 5^. (Original.) 
(Specimen in the Kgl. Universitats-Frauenlilinik 
in Konigsberg. ) 



Shape. 



SPECIAL DIAGNOSIS 



263 



Consistency. 



sition of the tumor, the proportion of the two fundamental substances — 
connective tissue and muscle; the more connective tissue, the harder 
the myoma, and the more muscle, the softer the tissue. 
Pure fibromata, particularly if they are subserous, may feel 
as hard as stone: while a pure myoma may be as soft as a gravid uterus. 
The latter are often impressible (doughy) and give apparent fluctuation. 
The thicker the layer of uterine muscle overlying the myoma, the softer 
will be the consistency. Most myomata are 
hard, unyielding and distinctly firmer than 
healthy uterine muscle. Before menstru- 
ation myomata undergo a characteristic 
change in consistency, becoming softer on 
account of the greater vascularity of the 
tissues; after the completion of the men- 
strual flow this temporary softness is replaced 
by the usual hard consistency- of the tumor. 

Marked c h a n g e s in 

the consistency of 

myomata are produced 

b}' pathologic processes 

in the substance of the 

tumors: 

The hardness is 

increased by cicatricial 

(senile) shrinking of the 

intermuscular connective 

tissue (induration) or 

by calcification, 

which is most frequent 

in subserous, and rarest in interstitial tumors. 

Calcification usually begins at the centre, occasion- 
ally at the periphery, and forms layers like the 

skins of an onion; as a result of this process the 

myoma may become as hard as stone. 
Softening, on the other hand, is a more important change 
because it not infrequently gives rise to diagnostic errors. It occurs 
almost regularly with the softening of the uterus during pregnancy, 
which also involves the myoma and renders it larger and 
softer; after parturition these changes slowly subside 
again. Necrobiotic processes in the myoma sometimes lead to fatty 
softening, which may go on almost to liquefaction of the tumor. It 
occurs during pregnancy, in the puerperium, and after other disturb- 
ances of nutrition. Total necrosis of the myoma, such as occurs in the 





Fig. 13-1. — Submucous 
Myom.a. (fibrous polyp) 
which has been expelled 
into the cervix and arrested 
at the external 03. Ji. 
(Original.) (From a speci- 
men in the Kgl. Univer- 
sitats-Frauenklinik in 
Konigsberg.) 



Fig. 1.33. — Submucous Myoma in 
Process of Expulsion, y^. (Orig- 
inal.) (From a specimen in the Kgl. 
Universitats-Frauenklinik in Berlin.) 
The cervix and external os are com- 
pletely dilated and the myoma has 
been delivered into the vagina; in 
front, bladder and urethra. 



Softening 



264 



GYNECOLOGICAL DIAGNOSIS 



puerperium and after curettage of the uterine mucous membrane, also 
renders the myoma softer. Inflammatory processes in the myoma and 
suppurations such as are most frecjuently seen with infections and dur- 
ing the expulsion of a submucous myoma, also cause the hard consist- 
ency to disappear. The greatest degree of softening is observed when 
an accumulation of fluid takes place in the substance of the tumor, 
whether it be the products of degeneration or a collection of lymph in 
the lymph-clefts of the connective tissue or in the greatly dilated 
lymph-vessels. Telangiectatic myomata are also characterized by 




Fig. 135. — Subserous Cervical MyOma (peeled out of the connective tissue) (posterior view). Y^. 
(Original.) (Specimen from the Kgl. Universitiits-Frauenkhnilc in Konigsberg.) 

great softness. As a result of sarcomatous degeneration a myoma 
may soften to the extent of spontaneous disintegration. 

The mobility of myomata depends upon their relation to the 
uterus. Submucous and interstitial myomata, which cause a uniform 
enlargement of the uterus, have the same mobility as the organ itself; 
Mobihty the excursions are occasionally limited only by the associated 

of Myomata. teuslou of the abdomiual walls and ligaments. Subserous 
myomata have a mobility of their own, depending in the main on the 
thickness of the pedicle. If the pedicle is very broad, they are limited in 
their excursions and follow the movements of the uterus; if the pedicle is 
thin, the mobility on the other hand may be very great and, if the abdom- 
inal walls are flabby, the myoma follows all the movements of the body. 



SPECIAL DIAGNOSIS 



265 



An entire absence of mobility is observed in myomata only 
under exceptional circumstances. Intraligamentary and subperitoneal 
tumors, even if they possess a pedicle, lose their mobility because they 
are firmly attached to the floor of the pelvis by the investing peritoneum; 
the mobility in these cases is hot completely abolished, however, as the 
peritoneum and surrounding connective tissue usually permit a certain 
degree of displacement. As a result of parametritic exudates or exten- 
sive perimetritic adhesions, which result from not infrequent com- 
plications with pyosalpinx, myomata become very firmly attached to 
adjacent structures, especially the pelvic wall. 
Incarceration also renders a myoma immovable. 
Thus a subserous myoma may completely fill 
the outer pelvis; or the uterus, enlarged by an 
interstitial myoma, may become incarcerated in 
the pelvis in retroflexion. The degree of immo- 
bility and the possibility of reposition in these 
cases depend upon the size of the myoma and 
the width of the pelvic cavity. 




Fig. 136. — Interstitial Cer- 
vical Myoma. H. (Original.) 
(From a specimen in the Kgl. 
TJniversitats - Frauenklinik in 
Konigsberg.) 



Diagnosis of Myoma. 

The diagnosis of myoma is principally and 
almost exclusively a palpatory diagnosis, and 
depends on the demonstration of a solid tumor 
of the uterine wall presenting the topographical 
relations and palpatory properties which have 
just been explained. The tumor may occupy 
the wall itself, it may project into the uterine 
cavity, or it may form a prominence on the 
outer surface of the uterus. Three different 
methods are employed in demonstrating the 
presence of uterine tumors — direct palpation of 
the tumor, palpation of the adnexa, and the use of the sound. 

The most important of these is palpation of the tumor and its 
attachment to the uterine wall ; hence in most cases combined exami- 
nation is all that is necessary. The findings of bimanual palpation will 
vary according to the variety of myoma present. 

Interstitial myomata can never be felt directly; they can 
be diagnosticated only by the increase in the thickness and size of the 
uterus. As long as the tumors are small, their presence can only be 
suspected if the uterus is large and of hard consistency. 
Occasionally the greater consistency of the myoma can be 
quite plainly distinguished from the softer uterine substance, or the 
tumor may be felt as a small protuberance on the outer surface of the 



Interstitial 
Myomata. 



266 



GYNECOLOGICAL DL\GNOSIS 



organ (Fig. 138). If the tumor is very large it maj' occasionally be 
difficult to prove that one is dealing with the uterus. The positive signs 
are, the finding of the junction or transition of the vaginal portion with 
the tumor itself and noting that the cervix follows the movements of 
the tumor. When by means of these signs a large tumor has been 
definitely recognized as the uterus, it must be regarded as a myoma 
whenever the consistency is hard (Fig. 139). The exact situation of 
an interstitial myoma in the uterus cannot always be determined by 
palpation alone. If palpation through the anterior vault or from 
the two sides demonstrates that the cervix is broadened above the 





V, 



Fig. 1.37. — Submucous Cervical Myoma (surface view and cross-sec. ..i. .. ..-ijecimen in the Kgl. Uni- 
versitats-Frauenklinik in Konigsberg.) (Original.) The Up of the cervix in which the myoma is lodged is 
thickened in tlie form of a hemispliere and surrounded by the otlier hp in the form of a crescent. 

vaginal vault and merges uniformlj" with the tumor, it is difficult 
to determine in which wall the mj^oma is lodged. But if the junction 
is found at the periphery instead of in the median line, and a portion 
of normal uterus can be felt at that point, it may be inferred that the 
cavity also lies there and that the myoma is accordingly on the other 
side. A simpler method of arriving at the desired result is the use of 
the sound (see p. 275). 

The diagnosis of interstitial cervical myoma can 
usually be made without any trouble b}^ the uniform nodular enlarge- 
ment of one cervical wall and the crescentic distention of the opposite, 
attenuated wall. If the myoma occupies the lower portion of the cervix 
it produces a large tumor which projects into the vagina and, if the 



SPECIAL DIAGNOSIS 



267 



external os is dilated, the bulging of the tumor into the lumen of the 
cervical canal can be distinctly recognized. The diagnosis is more 
difficult when a large tumor blocks access to the external os. 

The diagnosis of submucous myoma is based on the same 
principles as that of an interstitial tumor so long as the cervix remains 
closed. Occasionally the uniformly round shape of the uterus and the 
junction of the cervix with the exact centre of the tumor may indicate 
that it is of the submucous variety. A positive diagnosis of submucous 




Fig. 138. — Small Interstitial Myoma of the Anterior Wall. P.-F. ''/^,. (Original.) The uter- 
ine body is thick and hard, the lower uterine segment soft and thin; 9 cm. The anterior wall presents a 
spherical bulging. The sound shows a distinct difference in tlie tliickness of the uterine walls. 



myoma can be made only by direct palpation of the tumor when the 
cervical canal is open or the myoma is in process of being expelled 
(Fig. 140). Menstruation is a favorable time for making the diagnosis 
of a submucous myoma because the congestion which takes submucous 

place in the tumor during this time frequently excites Myomata. 

labor pains that dilate the cervix. After menstruation the myoma 
retires into the uterine cavity and the cervix closes up. Hence if in a 
case of severe menorrhagia there is reason to suspect a submucous 
myoma, an examination should, by all means, be made during men- 
struation. The finger introduced into the uterus feels either a hard 



268 



GYNECOLOGICAL DIAGNOSIS 



tumor in the uterine cavity, with a more or less extensive attachment 
to the uterine wall, or merely a spherical bulging of one of the walls. 

Case 19. I once made a curious mistake in examining the uterine cavity. I mistook 
a circumscribed bulging of the uterine wall for a myoma and operated. I very soon found 
out my mistake. Errors of this kind may certainly be avoided if attention is paid to the 
increase in thickness of the -wall at the bulging point. 

In order to determine the breadth of the connecting pedicle in 
submucous myoma when it cannot be directly felt, Fritsch suggests 




Fig. 139. — Large Interstitial Myoma of the Anterior Wall. P.-F. %. (Original.) The uterus 
extends to within two fingers' breadth of the navel ; the sound, 12 cm., rises at the posterior wall and the 
tip is distinctly felt tlirough the tissues at the upper pole of the tumor. 

that the myoma be grasped with Muzeux forceps and a rotary move- 
ment imparted to the uterus. The greater the rotation, the thinner 
must be the pedicle. As this method may, however, occasionally cause 
infection of the myoma, it should be employed only when immediate 
removal of the tumor is contemplated. 

The diagnosis of small submucous myomata is always uncertain 
as long as the cervix remains closed, because the uterus, if the 
wall is not specially thick, is not necessarily enlarged or thickened. I 
have not infrequently found a submucous myoma the size of a walnut 
in a uterus of absolutely normal size and once even in an abnormally 



SPECIAL DIAGNOSIS 



269 



small uterus; hence in cases of long continued and constantly recur- 
ring hemorrhage, particularly if associated with dysmenorrhea, one 
should think of a submucous myoma and satisfy one's self as to its 
presence or absence by exploring the uterine cavity with the finger. 
Submucous myoma may occasionally be suspected on account of the 
balloon-shaped enlargement of the cervix when the tumor has been 
expelled from the uterine body and arrested behind the external 
OS like a cervical abortion; the vaginal portion in these cases becomes 




Fig. 140. — Submucous Myoma in Process of Expulsion. P.-F. 3^. (Original.) The lower pole 
of the myoma is conical to adapt itself to the uterine cavity and cervical canal; the external os admits one 
finger; a small portion of the cervix is still' undilated. 



spherical and the myoma can be felt through the contracted os. The 
tumor can also be felt with the sound through the narrowed os; or, 
after incision of the os, with the finger. 

Submucous cervical myomata are, as a rule, easily accessible to 
direct palpation, because they early cause dilatation of the external os 
and project into the vagina; the pedicle connecting the tumor with the 
cervical wall is readily palpated. 

Subserous myomata are recognized by palpation more easily 
than any others. So long as they are small they appear as nodules or 
pedunculated tumors on the outer surface of the uterus and are usually 



270 



GYNECOLOGICAL DIAGNOSIS 



of hard consistency. In the case of large tumors, on the other hand, 
the physical signs depend on the nature of the connection with the 
uterus; if the attachment is very broad, the myoma and the uterus 
Subserous togcthcr form a single tumor and the unaffected remain- 

Myomata. j^^. ^f utcrus Can bc recoguized only in one place by a 

protuberance, a margin or edge, or the softer consistency of the uterine 
muscle, or the junction of the cervix with the soft uterus (Fig. 142). 
The narrower the connection between the myoma and the uterus, the 
more difficult is the diagnosis of the uterine growth because the charac- 




FiG. 141. — Subserous Myoma of the Anterior Wall. P.-F. %. (Original.) Myoma as large as a fist, 
with base about the size of a dollar springing from the anterior wall. Uterus 8 em. 



teristics become more and more those of a tumor situated alongside of 
the uterus. If the pedicle is distinct, the uterus and the tumor can be 
felt separately and the diagnosis of myoma is based chiefly on the 
nature of the pedicle. The latter always possesses a certain consistency, 
is usually broad and short, and has a fleshy feel (Fig. 141). The 
diagnosis of svibserous myomata is rendered difficult by the fact that 
they frequently lose their characteristic spherical shape; while, on 
the other hand, the diagnosis is simplified by the distinctly hard 
consistency of the tumors. 

The diagnosis of an intraligamentary m5^oma is based on 
the connection of the tumor with the lateral surface of the uterus. 
The attachment may occupy the entire lateral aspect (Fig. 143) or 



SPECIAL DIAGNOSIS 



271 



may be very thin. Occasionally the myoma is completely separated 
from the uterine wall. Displacement of the uterus to one side, so 
that the organ projects deep down into the parametrial or paravaginal 
tissue, diminished mobility of the tumor, and the charac- 
teristic course of the adnexa (see p. 275) also point to 
intraligamentary myoma. The tumor may be assumed to 
be subperitoneal if it originates at a point on the uterus 
where there is no peritoneal attachment or the serous membrane is 
only loosely connected; such tumors are always deep-seated, corporeal 
or cervical myomata. In these cases a considerable portion of the 
uterine body, which is displaced upward or far to one side, can be dif- 



Intraligamen- 

tary and 

Subperitoneal 

Myomata. 




Fig. 142. — Three Subserous Myomata of the Uterus. P.-F. Y^. (Original.) On the right, 
a myoma the size of a fist ; on tlie left, a smaller subserous myoma ; in the surrounding mantle of uterine 
tissue below the tumor a very small nodule can be felt. The fundus of the uterus can be distinctly demon- 
strated with the sound, forming a saddle-shaped connecting piece between the two myomata. Soimd 11 em. 

ferentiated from the myoma (Figs. 143 and 144). Intraligamentary 
myomata have a limited mobility, particularly from above downward, 
and cannot be displaced out of the true pelvis. 

Palpation of the adnexa plays an important part in the diagnosis 
of myomata because without it the seat and variety of the tumor can- 
not be recognized with certainty. In every case an attempt should be 
made to determine the course of these structures, although palpation of 
unfortunately palpation is often impossible on account of ^^^ Adnexa. 
the thickness of the abdominal walls. It is most important to trace 
the course of the round ligaments. The ligament is searched for 
immediately above the horizontal ramus of the pubic bone by forcibly 
depressing the abdomen with the external hand and passing the fingers 
to and fro in a direction perpendicular to the course of the ligament. 



272 



GYNECOLOGICAL DIAGNOSIS 



If a firm cord is felt at this point, its course must be traced to the 
tumor for as great a distance as possible by using moderate pressure; 
the closer the connection between the ligament and the myoma, the 
more difficult it is to palpate it separately. If the round 
ligaments join the tumor and can be traced as far as the 
dome, it shows not only that the mass is a uterine tumor but, in 
a;ddition, the position of the fundus can be determined by the course 
of the ligaments and the location of their junction with the tumor. 



Round 
Ligaments. 



Ovarsin 



Tab.stn. 



ODordext. 
Zig.rot. dext. 




Ovaries. 



Fig. 143. — Intralig.^mentart Myoma of the Entire Left Uterine Wall. P.-F. M- (OriginaL) 
The right adne.xa are not altered. The left ovary occupies a position on the dome of the tumor, and the 
long-drawn-out left tube is above, on the anterior surface, while the left round ligament rotates downward 
from the anterior surface. Part of the myoma has developed below in the pelvic connective tissue. 

The position of the ovaries is also affected by the presence 
of myomata because they are fixed to the lateral surface of the fundus 
by the short and unyielding ovarian ligaments; the latter 
can be felt only in exceptional cases when the walls of 
the abdomen are thin; they mark a path between the fundus and 
the ovary. The tubes usually cannot be felt except occasionally in 
intraligamentary myomata, when they may be demonstrated as thin 
cords that roll under the finger. 

The seat of the myoma and the direction of its growth can be 
accurately determined by the course of the round ligaments, 
approximately in the following manner: 



SPECIAL DIAGNOSIS 



273 



If a subserous myoma is attached to the uterus exactly at the 
fundus it forms a large fundal tumor, and the round ligaments as well 
as the ovaries are not in relation with the tumor, but are situated 
underneath (Fig. 145j). 

If the myoma is situated in the uterus below the origin of the round 
ligaments, the latter are pushed upward and, if the tumor is symmet- 
rically placed, the ovaries are found more or less displaced upward on 
each side of the tumor. This condition is seen with interstitial and 
submucous myomata (Fig. 142 and 145,). 




Fig. 144. — Retroperitoneal Myoma of the Posterior Cervical Wall. P.-F. K. (Original.) 
Myoma of the posterior wall the size of the fist. Above is the partly movable uterine body. Sound 11.5 cm. 
The cervical canal admits one finger. 



If the myoma occupies one wall of the uterus and causes distention 
— generally upward — of that wall, the uterus is oblique; on one side 
the round ligament is given off low down, on the other high up and 
passes obliquely over the tumor; one ovary is placed low down, the 
other high up on the tumor (Fig. 145.,). 

With intraligamentary tumors the adnexa arc found free by the 
side of the uterus on one side, while on the other side they are forced 
apart to such an extent that the round ligament occupies the anterior, 
and the ovary the posterior side, while the tube usually passes through 
the dome of the tumor (Fig. 145J. 

18 



274 



GYNECOLOGICAL DIAGNOSIS 



In myoma of the posterior wall the round ligaments join the 
anterior periphery of the tumor and the ovaries also are usually felt 
in front (Fig. Ho^). 

In myoma of the anterior wall the course of the ligaments is 
entirely posterior and the ovaries are crowded far down into Douglas' 
space (Fig. 140g). 

In the case of cervical myomata the adnexa are not affected and 
retain their position alongside of the body, except that they are 
displaced upward along with the fundus by the myoma (Fig. 146). 




Fig. 145. — Course of the Round Ligaments in the various forms of myoma. (Schematic.) (Original.) 

(For explanation see text.) 



Use of 
the Sound 



Sounding is an extremely important procedure in the diagnosis of 
myomata, but its application is unfortunately very limited because it is 
attended with dangers which are particularh' apt to occur in the case of 
myomata. The greatest danger is infection of the uterine 
cavity with vaginal germs, and this must by all means be 
avoided in the case of myomata which are to be operated upon; hence 
the procedure should not be employed at all when an operation 
is in prospect. Perforation readily occurs in the presence of myoma 
because the uterine wall is very much attenuated; and, on account of 
the irregular course of the uterine cavity, injuries of the mucous mem- 
brane and of the myoma cannot always be avoided. The sound should, 



SPECIAL DIAGNOSIS 



275 



therefore, be used onlj'- when the desired information cannot be ob- 
tained by means of combined examination and palpation of the adnexa. 
In addition the use of the sound is attended by a number of difficulties. 
Often it is impossible to introduce the instrument, or it may catch in 
the projecting myoma or in the uterine wall and convey the impression 
that the fundus has already been reached; or the sound at the first 
trial may enter one cornu of the uterus and at the second trial the 
other, greatly distended cornu, and in that way very variable results 
are obtained. Hence the employment of the sound requires great care 
in the technic and in the interpretation of the findings, but with this 
precaution it is a very excellent diagnostic aid, and in many cases a 
positive diagnosis of myoma cannot be made without it. 




Fig. 146. — Course of the Adnexa in" a Cervical Myoma. P.-F. ^-t. (Original.") Intraliga- 
mentary cervical mj'oma of the left wall. The appendages are easily palpated above, alongside of the body: 
only the lower portions of the round ligaments can be felt. 



The objects of sounding are various. In the first place the 
uterine cavity can be found within the tumor; if the sound enters 
the tumor, or if the head of the instrument can be felt at some 
point on the periphery, or a large portion of the sound can be 
palpated through the wall, we know that the cavity lies within the 
tumor and that the latter is, therefore, in all probability, a uterine 
myoma. In the case of interstitial myomata it is possible to 
determine, by demonstrating the cavity with the sound, which wall 
of the uterus contains the myoma. If the myoma is subserous, the 
part of the uterus which has not become enlarged can be demonstrated 
by feeling the tip of the sound through the muscle. The most impor- 
tant information obtained with the sound is the length of the 
uterine cavity. The latter is always elongated even when 



276 



GYNECOLOGICAL DIAGNOSIS 



only- part of the myoma occupies the uteriuo wall; the only excep- 
tion to this is found in the case of subserous myomata connected with 
the uterus by a thin pedicle, in which the cavity may be of normal 
length. The shape of the uterine cavity can also be determined 
by means of the sound, inasmuch as a limited excursion of the instru- 
ment indicates a normal cavity, while in the presence of marked dilation, 
as, e.g., with interstitial myoma, the sound can easily be moved about in 
various directions. The greatest excursions are experienced in the case 
of submucous myomata and it often seems as though the instrument 



were gliding over a prominence (Fig. 147 



The 



diagnosis 



of submucous myoma with the sound is by no means so 
positive as might be supposed. While small, hard myomata are 
not likely to be missed, the sound may pass completely around a 
large tumor without its presence being recognized. In several 






Fig. 147. — Shape of the Uterine Cavity in (1) Subserous, (2) Interstitial, (3) Submucous Myoma. 

(Schematic.) (Original.) 



instances I have failed to recognize large submucous tumors 
although I paid every attention to this point in my examination. 
Under such conditions the only way to make a positive diagnosis is by 
digital exploration. 

In the presence of a conglomeration of various tumors orientation 
may be exceedingly difficult. The examiner should first attempt to 
find the fundus, which is usually at the point where the bases of the 
various myomata come together. In order to find the uterus we then 
determine by palpation which part of the tumor is most directly joined 
to the cervix, or we find a point of the tumor from which pressure is 
most distinctly transmitted to the cervix. If this method fails, we try 
to recognize the fundus with the sound or to determine its position by 
the course of the round ligaments, taking advantage also of the differ- 
ence in consistency between the soft uterine muscle and the hard myoma. 
After the uterine body has been positively demonstrated, the connec- 
tions between it and the individual myomata are determined by the 
above mentioned palpatory findings and results obtained by sounding. 



SPECIAL DIAGNOSIS 277 

In comparison with that of the objective signs, the diagnostic value 
of the symptoms and history is insignificant. There is no symptom 
that apphes only to myoma, although hemorrhage, dysmenorrhea and 
sterility are observed much more frequently than in the case of other 
abdominal tumors. The important question whether a large tumor 
originates in the uterus or in the ovary cannot be decided by the pres- 
ence of the above symptoms, which are in the main uterine, as the same 
symptoms may be produced by ovarian tumors or the latter may happen 
to be present at the same time. 

Differential Diagnosis. 

In accordance with the different results obtained by palpation 
in cases of subserous, interstitial and submucous myomata, a number 
of pathologic conditions must be considered in the differential diagnosis. 

Subserous myomata are tumors which develop outside, subserous 

or alongside of the uterus and are therefore most apt Myomata. 

to be confounded with tumors of the aclnexa or the parametrium. 

From a practical standpoint the differential diagnosis between 
myoma and an ovarian tumor is the most important. 

Retro- uterine hematocele and intraligamentary hema- 
toma may resemble myomata if the consistency is more or less firm 
owing to coagulation of the blood and inflammatory reaction in their 
neighborhood; although even under these circumstances the consistency 
rarely becomes so uniformly hard as that of a myoma. Another 
point of difference is the broad connection between hematomata 
and the adjacent structures, particularly the pelvic wall, which is 
entirely absent in myoma unless it is complicated with an exudate. 
By reason of this broad connection, which is produced by the coagula- 
tion of the blood and the subsequent formation of adhesions with the 
uterine wall, the hematoma is always in intimate contact with the 
uterus, whereas subserous myomata are attached to the uterus by a 
more or less broad base or a pedicle. The differential diagnosis between 
intraligamentary hematoma and myoma is much more difficult because 
the characteristic features of both tumors are obscured by the invest- 
ing peritoneum and the reaction in the connective tissue. As large 
hematomata are almost always the result of disturbed tubal pregnancy, 
the diagnosis will usually be suggested by the characteristic history of 
that condition. In doubtful cases distinct shrinking is observed in the 
course of a few weeks' observation, while a myoma remains stationary. 

For the difference between subserous myomata and exudates, 
see the latter. 

For the difference between subserous myomata and pyosalpinx, 
see the latter. 



278 GYNECOLOGICAL DL4GNOSIS 

.Not infrequently a subserous myoma is mistaken for the uterine 
bod}^, particularly if it is exactly the same size and joins the cervix in 
the same manner. It is often difficult to decide by the shape and size 
alone which of the two masses is the uterus and which the myoma; 
occasionally the question may be decided by the consistency, which is 
harder in the myoma; if not, it can always be done by introducing 
the sound. One horn of a bicornute uterus is often mistaken for a 
subserous myoma, an error which can best be avoided by introducing 
the sound into both cornua, or by the adnexa which in the case of 
uterus bicornis must originate in the outer surface of the tumor, while 
in the case of subserous myoma they must both originate from the 
other tumor, the uterus. 

The physical signs of tumors of the round ligaments fre- 
quently cannot be distinguished from those of subserous myoma if 
they are limited entirely to the abdomen. As they are usually fibro- 
myomatous tumors, the consistency is also hard, and practically no 
differences are observed as regards the connecting pedicle, shape and 
mobility. As soon as part of the tumor has broken through the inguinal 
canal, a solid portion makes its appearance in front of the external 
ring which may resemble hernia? of various kinds; but the connection 
between this extra-abdominal portion and an intra-abdominal tumor of 
the above described character situated in a corresponding region makes 
the diagnosis of fibromyoma extremely probable. 

Interstitial myomata are likely to be mistaken only for conditions 
which lead to more or less uniform enlargement of the uterus. The 
distinction which the physician is most frequently called upon to make 
Interstitial is bctwceu au interstitial uiyoma and pregnancy. AVhile 

Myomata. j^j. -g ^^^ obvious mistake on account of the similar shape of 

the uterus, and while it has often been made by less experienced exam- 
iners in actual practice, a positive decision is nevertheless possible in 
almost every case. During the early months of pregnancy the differ- 
ential diagnosis is difficult because at this time softening may still be 
very slight ; but if the latter symptom is present anywhere, either in 
the vaginal portion or in the body, pregnancy is the more probable 
condition. When a myoma is present the uterus is often harder and 
more tense than a non-gravid uterus, and occasionally a distinct dif- 
ference in consistency can be recognized between the myoma and 
the uterine muscle. If, e.g., the myoma occupies the upper portion 
of the uterine body, Hegar's sign may often be simulated by the 
softening below the tumor. The most difficult decision is that be- 
tween myoma and early pregnancy with a dead fetus, be- 
cause the softening ma}^ subside altogether; but in this condition 
a remnant of compressibility of the lower uterine segment is partic- 



4kL 



SPECIAL DIAGNOSIS 279 

ularly valuable; not infrequently a slight bluish discoloration and 
softness of the vagina persist. The larger the myoma, the easier will 
be the differential diagnosis because the softening ought to be 
greater at the corresponding period of pregnancy. A soft consistency 
of the tumor is the characteristic feature of pregnancy. Not in- 
frequently, however, myomata become so soft from the accumu- 
lation of fluid or degenerative conditions as greatly to resemble 
the gravid uterus in consistency; but the softening of the vaginal 
portion and of the vagina, which is practically never absent in preg- 
nancy at this period, is rarely found. An almost absolutely positive 
sign of pregnancy is a change in the consistency. Uterine contrac- 
tions occur very rarely with mj^omata and must be interpreted as the 
labor pains of pregnancy. 

I have seen one case which showed that even this sign is not reliable. 

Case 20. Mrs. E., age 53. Tumor the size of a man's head in the median hne, easily- 
recognized as the enlarged uterus by its junction with the vaginal portion. Consistency 
distinctly cystic. Several times in the course of my observation I found the tumor hard 
and firm, but the change in consistency always occurred so gradually that I could never 
demonstrate a direct transition from a cystic to a solid consistency or vice versa. There was 
no doubt, however, that the uterus was contracting. The tumor when removed was found to 
contain a large unilocular cyst, surrounded by uterine wall tlie thickness of the finger, which 
bad contracted from time to time on the cyst. 

If the myoma extends above the umbilicus, pregnancy can be 
excluded with a tolerable degree of certainty because at this time fetal 
signs should be present. Difficulties may arise in the case of extra- 
uterine pregnancy or pregnancy with a dead fetus. Diagnostic diffi- 
culties always arise from the tendency of the gravid uterus to contract 
isolated portions of its walls, which, b}^ causing constriction and an 
increase in hardness, simulate myomata. The temporary character of 
these phenomena and the distinct softening observed in other places 
establish the diagnosis of pregnancy. 

The history is of some value in the differential diagnosis inasmuch 
as complete amenorrhea corresponding in duration to the size of the 
tumor is in favor of pregnancy, whereas regular menstruation is more 
indicative of myoma. It must be emphasized, however, that mistakes 
are frequently made on account of the occurrence of irregular hemor- 
rhages which are mistaken for menses and on account of amenorrhea 
due to other causes; hence the importance of the history is much less 
than that of the objective signs in the hands of an experienced ob- 
server. Keeping the patient under observation is of much more value; 
if the fetus is living, all doubts can be removed within a month. 

The difficulty of the differential diagnosis between pregnancy and 
myoma is illustrated in the following case: 



280 GYNECOLOGICAL DIAGNOSIS 

Case 21. A -woman of 55 is sent to the hospital for a myomotomy. A tumor of the 
size and shape of the uterus in the first months of pregnancy is found with its upper boundary 
at about the level of the navel. The consistency of the tumor is doughy and soft. The round 
ligaments pass through the dome of the tumor. Fetal signs, fetal parts and heart sound or 
fetal movements cannot be demonstrated. The vulva is not discolored; the vagina is some- 
what bluish red; the posterior lip is the color of wine yeast and somewhat soft. The patient 
says that her menstruation has been regular until three months ago and that she has suf- 
fered from nausea for the past three weeks; but she does not consider herself pregnant. Preg- 
nancy was considered on account of the softness of the tumor and of the vaginal portion 
and on account of the history; it could not be positively proven, however, on account of 
the absence of fetal signs and was furthermore improbable on account of the patient's ad- 
vanced 'age. Diagnosis was therefore reserved. At an examination made a few days later a 
doubtful change of consistency was demonstrated, estal:>lishing the diagnosis of pregnancy. 
At the abortion which occurred a few days later a large blood mole was evacuated. 

Interstitial myomata not exceeding the size of a fist are sometimes 
very difficult to distinguish from chronic metritis. The histoiy 
contributes little of value to the diagnosis, as small myomata are fre- 
quently accompanied by inflammatory symptoms both at the beginning 
and during their subsequent growth; on the other hand a positive 
result may be obtained in favorable cases by combined examination. 
The enlargement of the metritic uterus is usually uniform in all direc- 
tions, while in the presence of myoma the wall is often enlarged asym- 
metrically; the muscle in metritis is somewhat soft and painful during 
the recent stage, becoming hard and unyielding only when the disease 
is chronic, while in myoma the uterine wall is hard and tense and the 
tumor can often be differentiated from the healthy muscle by its con- 
sistency; besides, a myoma is rarely painful. The state of the cervix 
must also be considered in making the diagnosis. Chronic metritis 
usually involves the cervix, and both uterine body and cervix are uni- 
formly thick and hard and the cervico-corporeal angulation is rigid, 
whereas in myoma the cervix remains soft and slender. A decision 
can usually be made quite easily with the sound. Whereas in chronic 
metritis the instrument enters the middle of the uterus and can be felt 
equally well through the wall at any point, it will deviate to one side in 
the presence of myoma and a distinct difference will be noted, depending 
on whether the sound is felt through a myomatous or through a 
normal uterus. If the uterus becomes distinctly enlarged in the 
course of time, the diagnosis of myoma is positive. 

Submucous myomata. When the cervix is completely closed, 
the physical signs are similar to those of interstitial tumors; 
like the latter, submucous myomata are occasionally mistaken for 
Submucous pregnancy or chronic metritis. On the other 

Myomata. fiaud, if the ccrvlcal canal is open and the finger 

can be inserted into the uterine cavity, the conditions found 
are quite characteristic (see p. 267). Nevertheless the tumors are 



SPECIAL DIAGNOSIS 281 

not infrequently mistaken for other, similarly formed intra-uterine 
growths, particularly abortion in the second month. So-called cervical 
abortion, in which the mass is arrested behind the closed external os, 
and the cervix is enormously dilated and tightly stretched, contrasting 
with the empty, but somewhat enlarged uterine body above, produces 
a picture quite similar to that of a submucous myoma in a nullipara 
after it has reached the external os in the process of expulsion. 
An intact ovum also, although still entirely in situ, may produce the 
same conditions within the uterus that are found in submucous myoma. 
The distinction is made by the physical signs of pregnancy and by the 
data obtained from the history, especially the softening of the vaginal 
portion and vagina. If the polypoid body can be seen or felt in its 
entirety, the diagnosis is more certain. Fetal parts usually appear 
black from the presence of infiltrating blood, while myomata that are 
still situated in the cervix do not become gangrenous and the mucous 
membrane is usually of the normal red color. On palpation the fetal 
part is recognized by its friable consistency and the ease with which it 
can be separated from the uterine wall, while myomata have a smooth 
surface and firm consistency and are organically united to the uterus. 
The greatest difficulties arise in the distinction between a retained 
ovum that has died early in the course of pregnancy and a submucous 
myoma; under these circumstances also the fact that the tumor can be 
easily crushed and separated from the uterine wall suggests that it is a 
product of gestation. The history in a case of pathologic pregnancy 
may be misleading on account of continued hemorrhages. 

The distinction between fibrous polyps and mucous polyps 
is of practical importance. In pronounced cases it is not difficult to dif- 
ferentiate between the two: in comparison to the round shape, smooth 
surface and firm consistency of submucous myomata, mucous polyps 
are usually oval and often lobulated or divided into several sections; 
the surface in most cases is irregular from the presence of retractions 
and lacunae, rarely smooth; quite often follicles that have ruptured 
project above the surface and in some places mucus is seen escaping 
from the follicles. The mucous membrane is bright red and 
bleeds easily, unless changes (metaplasia) have taken place in the 
epithelium of those portions which project into the vagina, in which 
case it is pale-red or violet, like vaginal epithelium. The pedicle of 
mucous polyps is usually much thinner and their consistency in the 
main much softer; although myomata in process of expulsion may also 
become soft and edematous. In a great many cases the physical signs 
are so obscure that a clinical diagnosis is not possible; even with the 
microscope the classification of polyps is by no means always easy 
because so many transitional forms occur. 



282 GYNECOLOGICAL DIAGNOSIS 

If the submucous myoma is in the vagina and is of suitable size it 
may be mistaken for the inverted uterine body. From a prac- 
tical standpoint it is exceedingly important to differentiate sharply 
between these two conditions. The error in almost every case consists 
in mistaking an inversion of the uterus for a myoma — not vice versa — 
and operating for the purpose of removing the tumor, a mistake which 
may be followed by the most regrettable consequences to the patient. 
In order to escape such a serious error it is important to exclude all 
possibility of inversion in every case of submucous myoma large enough 
to be mistaken for that condition, before deciding to extirpate the 
tumor. The distinction between the two conditions is based on the 
relation of the tumor to the cervix and the uterine body. In cases of 
inversion, if the cervix is still partially preserved, the junction of the 
neck of the tumor with the inner wall of the cervix is easily felt by the 
palpating finger introduced high up in the cavity; whereas the polyp is 
connected to the wall only at one point and on the other side the finger 
can be carried past the pedicle and introduced into the upper portion 
of the cervix. If the finger cannot be introduced far enough, the sound 
is employed, with the aid of which the junction of the inverted uterine 
body with the inner surface of the remaining cervical portion can also 
be felt everywhere ; whereas in the case of polyps the instrument glides 
past the tumor on one side and penetrates far into the uterine cavity. 
The differential diagnosis can however be made much more certainly 
by bimanual examination, in most cases through the rectum and abdom- 
inal walls. In the case of submucous myomata the uterus — of normal 
size unless enlarged by other myomata — is felt above the tumor, whereas 
in inversion the palpating fingers come together immediately above the 
cervix and the inversion-funnel can be recognized from above, particu- 
larly in anesthesia. Partial inversion is more difficult to recognize 
because the uterus is felt above the cervix; careful examination, how- 
ever, shows that the uterus is too small and presents a distinct depression 
at the lateral aspect or, more frequently, at the fundus. The signs 
presented by the tumor in the vagina are all more or less ambiguous. 
The size in both cases may happen to be the same. The consistency of 
the inverted uterine body is usually somewhat softer and more yielding, 
but a myoma may also lose its hard consistency as the result of secondary 
changes; the mucous membrane appears red on both, unless gangrene 
develops, although the surface of the inverted uterus is often somewhat 
rough; the menstrual escape of blood from the mucous membrane, 
which might suggest the possibility of inversion of the uterus, is gener- 
ally obscured by irregular hemorrhages. The only sign obtained by 
inspection with the speculum which might lead to the diagnosis is the 
demonstration of both tubal orifices, especially if they can be sounded. 



SPECIAL DIAGNOSIS 283 

Large round tumors of the vaginal wall, with smooth sur- 
face, such as sarcoma and in rare cases of carcinoma, as well as large 
round tumors of the vaginal portion, are differentiated from 
submucous myomata most easily by their relation to the cervical canal. 
If the finger can be introduced high enough — in anesthesia if necessary 
— to feel the pedicle disappearing into the cervical canal, the diagnosis 
of myoma is assured; if it cannot be reached with the finger, the fact 
that the tumor becomes narrower as it approaches the vaginal portion 
and the absence of any connection with the vaginal wall may suffice 
for the diagnosis. Occasionally secondary adhesions, which must 
not be mistaken for pedicles, may be felt between a myoma and the 
vaginal wall. They usually yield readily to the pressure of the finger. 

Diagnosis of Certain Complications. 

In the course of the development of a myoma, which may be quite 
protracted, complications not infrequently arise either in the tumor 
itself or in the adjacent organs as a result of its presence. The clinical 
picture as a whole may be considerably modified by these complica- 
tions, and it becomes a physician's duty to recognize them in time to 
apply the proper treatment; while, on the other hand, their recognition 
is important because the principles on which the diagnosis of simple 
myomata is based cannot always be applied to the complications also. 

The complication of pregnancy and myoma is particularly 
important and its diagnosis is difficult. The importance lies in the fact 
that degenerations of various kinds develop in myomata under the 
influence of pregnancy and, on the other hand, the presence of a myoma 
may seriously interfere with the course of gestation, parturition and the 
puerperium. The diagnosis is difficult because, in a gravid uterus 
the seat of myomata, the signs and symptoms of the two conditions are 
both present and mutually modify one another. The principal changes 
in the gravid uterus, increase in size and softening, cannot be easily 
demonstrated in the myomatous uterus because it is itself enlarged and 
the consistency is hard. Hence softening is never found in the entire 
organ, being present only in that portion of the uterine wall which is 
free from myomata. If, e.g., the cavity is completely surrounded by 
interstitial and subserous myomata, softening is absent altogether; 
again, the sign is not available if that portion of the body which becomes 
distinctly softer occupies a region not accessible to palpation, e.g., the 
posterior part of the organ. Another factor which renders this valuable 
diagnostic sign of simple pregnancy uncertain in the presence of myomata 
is that these tumors from the beginning vary greatly in their consistency 
and may become as soft as the gravid uterus from the presence of zones 
of cystic degeneration. Softening of a definite portion of the tumor is of 



281 GYNECOLOGICAL DL\GNOSIS 

positive value only if it can be shown that the softening is increasing 
and that the corresponding segment of the tumor was previously solid, 
especially if the latter can be identified as the uterine body by the 
course of the round ligaments. Before the third or fourth month I 
have practically never been able to make a diagnosis of pregnancy 
based on softening of one portion of a tumor. 

The same uncertainty attaches to the second sign — enlargement 
of the uterus. Whatever enlargement is observed is at first referred 
to th-e myoma, and it is only when the enlargement is exceptionall}^ 
rapid or confined to a definite portion that the phenomenon is of value. 
In some of my cases the occurrence of pregnane}^ was indicated by the 
statement on the part of the patient that the myoma had grown rapidly 
during the last months. In such cases the myoma itself does not enlarge; 
it is merely elevated more rapidly on account of the increase in size of 
the gravid uterus below. It is evident that the diagnostic difl&culties 
are much less in the case of pregnancy with a subserous myoma or an 
interstitial growth involving only one wall; in fact whenever the 
entire uterus or at least the greater part of it can be palpated in the 
non-gravid state, the changes produced in the organ by pregnancy 
can also be recognized. 

Owing to the uncertainty of the signs of pregnancy in the body of 
the uterus, the value of the signs in the vaginal portion and in the vagina, 
which are easily recognized, is much greater. Marked softening of these 
parts, particularly if progressive, and a distinct bluish discoloration are 
valuable factors in the diagnosis. The last doubts are often dissipated 
by the history of amenorrhea. The cessation of menstruation in a 
sexually mature woman should always excite the suspicion that concep- 
tion has taken place in the myomatous uterus, and if the physician's 
suspicions have thus been aroused he will not fail to interpret the first 
changes in the uterine bod}^ correctly. To be sure, pregnancy may 
exist without amenorrhea. For, on the one hand, regular menstruation 
may occur several times in the case of myoma owing to the hyper- 
plastic condition of the endometrium; and, on the other hand, irregular 
hemorrhages which presage a later absorption often occur early. Occa- 
sionally the occurrence of pregnancy may be revealed by the appearance 
of new symptoms; the patient often complains of increased pain and 
bladder symptoms at the very beginning of pregnancy. 

In spite of the many changes that occur at the beginning of preg- 
nancy, it frequently happens that the condition is overlooked in the 
early months. During the later months the diagnosis is always easier 
because the gravid portion of the uterus is always larger than the myoma, 
and the fetal signs become more and more distinct. The mistakes 
which are made during the later months consist in failure to discover 



SPECIAL DIAGNOSIS 285 

the myoma or in mistaking it for fetal parts. When small myomata 
in the gravid uterus are in a favorable situation for palpation they are 
recognized by their hardness, which, to be sure, is somewhat modified 
by the general softening of pregnancy, and by their situation in the 
uterine wall. It must be remembered that the pedicles of myomata, 
which may at first be quite distinct, may broaden out as a result of the 
constant distention, greatly increasing the area of attachment. If the 
myomata are situated in the posterior wall, in the fundus under the 
dome of the diaphragm, or in the region of the kidneys under the intes- 
tines, they may entirely escape palpation. The error of mistaking them 
for fetal parts may be avoided by remembering that the latter are under- 
neath the uterine wall, that they can be moved about under the wall, 
and disappear when the uterus contracts; whereas myomata are 
exterior, are rendered moi'e distinct by the uterine contractions, and 
can be displaced only on or with the uterus. The mistake is partic- 
ularly apt to be made if the myomata resemble, in shape and size, 
the two large fetal parts. 

Complications with inflammatory diseases in the neighbor- 
hood are very frequent in the case of myomata. The inflammation 
may be caused by the myoma or may have no connection with it. The 
importance of this complication is twofold: in the first place, a recent 
inflammation contraindicates operation and, after it has become chronic, 
renders it more difficult; in the second place, symptoms which are 
exclusively caused by the inflammation, such as pain, may be 
erroneously referred to the myoma and a false significance may be 
attached to the tumor. 

The frequency with which inflammatory comphcation is the cause of so-called myoma- 
tous pain is shown by the fact that out of 57 cases of myomata, in which I made an accurate 
microscopic and clinical examination to determine the cause of the pain, it was found 19 
times in some inflammatory condition of a neighboring organ. 

Hence in all those cases at least in which pain is present, the phy- 
sician must examine for inflammatory processes. They are exceedingly 
frequent in the parametrium, in the form of bands or thickenings 
binding the cervix to the pelvic wall, and usually have no connection 
with the myoma. When they are pressed upon or stretched by dis- 
placing the cervix, pain is complained of. As these adhesions are readily 
accessible to palpation, the diagnosis is not difficult provided exami- 
nation of the parametrium is thought of at all. Perimetritis is 
more difficult to demonstrate. Adhesions, even when they unite different 
myomatous nodules, are never palpable, and pain on pressure, com- 
plained of during palpation of the serous surface, is much more likely 
to be due to changes in the myoma than to perimetritis. The only sign 
that indicates a probable previous perimetritis is fixation of the entire 



286 GYNECOLOGICAL DIAGNOSIS 

myomatous uterus or of individual nodules in the region of the serous 
investment. The most frequent complications under this head are 
inflammatory processes of the tubes, ranging from simple salpingitis to 
large retention tumors filled with pus or serous fluid. Even these 
alterations are usually difficult to recognize because smaller tumors hide 
among the myomatous nodules or, if their consistency is hard, are 
themselves mistaken for nodules. Cystic tumors are usually mistaken 
for ovarian tumors. If, on the other hand, tumors with indis- 
tinct' outlines and great sensitiveness on pressure are found in the 
situations where the adnexa are supposed to be, or if localized adhe- 
sions of the parietal peritoneum can be demonstrated at these points, 
tubal disease is probable, particularly if the process is bilateral. Certain 
statements on the part of the patient, such as the previous occurrence 
of one or more attacks of abdominal pain, inflammation, or hemorrhage 
occurring chiefly during hard physical labor, lifting, walking, etc., indi- 
cate that the symptoms are due to the inflammation rather than to 
some cause within the myoma. (For further details see the diagnosis of 
perimetritis, pelveo-peritonitis and tubal diseases.) 

Twisting of the pedicle is much more rare in myomata than in 
ovarian tumors on account of the shortness and thickness of the pedicle. 
Nevertheless it occurs just often enough in the case of subserous myomata 
with thin pedicles to demand notice on account of the gravity of the 
clinical picture that is produced. The latter is similar to that seen in 
torsion of ovarian tumors. Sudden pain in the abdomen, repeated once 
or twice, occurs either after a slight injury or spontaneously, becomes- 
localized in the myoma, and usually subsides again in the course of 
hours or days. Contrary to ovarian tumors the accident is rarely fol- 
lowed by peritonitis with adhesions, because owing to the greater thick- 
ness of the pedicle the circulation is not abolished and normal conditions 
are soon restored. Nevertheless the changes which are observed in the 
tumor show that the circulation is considerably impaired. 

The diagnosis is based on the above statements of the patient and on 
the great sensitiveness on pressure in cases of tumors with thin pedicles. 

Case 22. Miss R., in 1902, had a sudden prolonged attack of cramp in the right 
inguinal region lasting three days; in 1904 two more similar attacks, and in February, 1905, 
a final attack of the same kind; during the intervals complete freedom from pain. Exami- 
nation revealed a subserous myoma as large as the fist at the right aspect of the uterus, the 
pedicle of which at the operation was found to have become twisted one and one-half times 
around its own axis. 

Twisting of a uterus uniformly enlarged by an interstitial myoma 
is exceedingly rare and produces the same symptoms. 

The urinary complications demand careful consideration. Before 
the proper treatment can be instituted it must be definitely decided 



SPECIAL DIAGNOSIS 



287 



whether the urinary symptoms are due to a complicating condition of 
the bladder, or directly or indirectly to the myoma itself. Ischuria 
may be regarded as a mechanical disturbance of urination due to the 
myoma, whereas tenesmus, which is much more frequent, and dysuria 
may be due to a complicating cystitis or to the myoma alone. These 
symptoms are much too frequently attributed to the myoma, which is 
supposed by its position on the bladder to compress the viscus and 
interfere with its function. The first step in determining this point is 
to examine the urine (obtained by catheter) for signs of cystitis; if the 
findings are positive, the cystitis may be assumed as the cause of the 
symptoms and subjected to treatment at once. But even the absence 
of bladder constituents in the urine is not sufficient to prove that the 





Fig. 148.- — Otstoscopic Picture when the 
Floor of the Bladder is Greatly Elevated by 
A Submucous Myoma in the Vagina. The floor of 
the bladder, which forms a hemispherical bulging 
in the cavity, is illuminated only in its posterior 
portion. The urethral orifice is not illuminated. 



Fig. 149. — Cystoscopic Picture of a Cleft 
Bladder in a Case of Interstitial Myoma. 
Below, the anterior bladder wall with the crest 
of the symphysis ; above, the bulging posterior 
wall which is pushed in by the myoma ; between 
the two, the greatly contracted lumen of the 
bladder. 



myoma is the cause of the symptoms; for there are many other causes 
of strangury in the female which must be excluded. Such changes may 
be inferred from certain relations between the myoma and the floor of 
the bladder which can be determined by palpation ; but positive infor- 
mation can be obtained only with the cystoscope. The changes seen in 
the cystoscopic image are of two kinds: 

1. Even in the absence of infectious cystitis changes of a catarrhal 
nature occur in the mucous membrane. The vessels in the floor of the 
bladder, especially the larger veins, are greatly injected, while the 
membrane as a whole retains its normal color. An excessive amount of 
mucus is produced, which floats about in the urine in small flakes and ' 
adheres to the mucous membrane here and there, covering it with a 
grayish veil. Sometimes small floating mucous polyps are seen, particu- 
larly on the floor of the bladder. They resemble small papillary villi, 
are translucent and contain blood-vessels (Zangemeister). 



288 GYNECOLOGICAL DIAGNOSIS 

.2. Contraction of the cavit}' by the pressure of the myoma is much 
more common. The bladder is compressed from above downward or 
from behind forward, forming a ck'ft (Spaltblase, Fig. 149, Zangemeister) 
or the floor of the bladder is elevated (Fig. 148), pushed forward or 
displaced to one side, one or both ureters being always involved in the 
displacement. In other cases circumscribed portions of the bladder wall 
are invaginated by the pressure of myomatous nodes. 

Some of the changes which have just been described have much 
more 'importance than others as possible causes of urinary symptoms. 
Contraction of the bladder due to pressure from above rarely gives rise 
to symptoms. On the other hand, any cystoscopic changes in the floor 
of the bladder, where uterine tenesmus originates, circumscribed non- 
infectious catarrh, and moderate displacement of the floor of the bladder 
may always be regarded as positive findings. 

Diagnosis of the Degenerations. 

Myomata, the duration of which may extend over several decades 
until the menopause, when the tumor ceases to grow, or its operative 
removal, are subject to various kinds of degeneration. The significance 
of these degenerations varies. While certain structural changes, such 
as induration and calcification, may have no particular effect on the 
general condition, others like sarcoma may prove fatal after the disease 
has been present for years without causing any inconvenience. The 
degenerations also differ in the fact that some of them do not betray 
their presence by any clinical signs whatever (such as beginning soft- 
ening), while others are accompanied by such alarming symptoms 
(total necrosis) that the change in the situation is recognized at a glance. 
I shall confine myself to those forms of degeneration in which the 
diagnosis is important and possible. 

The malignant degenerations of uterine myomata are the 
most important. 

Carcinoma does not manifest itself in the form of a degeneration 
of the uterine myoma; while it is undoubtedly influenced by the tumor 
it develops independently of it, or may ultimately involve the myoma 
secondarily. Carcinoma makes its appearance in the cervix and pro- 
duces the same clinical picture as sarcoma when the uterine body is 
free from myomata; hence the diagnosis is based on the same principles 
(see diagnosis of carcinoma). Experience has taught us, however, 
that cervical carcinoma is often overlooked in cases of uterine myomata, 
the reason being that the examiner is so much taken up by the dis- 
covery of the myoma that he refers the symptoms of carcinoma to the 
myomatous tumor. This grave error can be avoided by systematically 
examining the other genital organs without preconceived opinion, 



SPECIAL DIAGNOSIS 289 

particularly if there are any symptoms pointing to carcinoma. In a 
few cases the diagnosis of carcinoma of the cervix is rendered impossible 
by the fact that a large myoma of the vagina renders the cervix inacces- 
sible, and the cancer is discovered only after removal of the myoma. 
The diagnosis is much more difficult if the carcinoma develops in 
the mucous membrane of the uterine body when the latter is the seat 
of myomata, a condition of affairs which may be expected in 1 per cent, 
of all cases of myoma, owing to the fact that the symptoms produced 
by the carcinoma, particularly pain and hemorrhage, do not differ 
sufficiently from those of the myoma and infiltration of the uterine 
wall, which belongs to carcinoma, is not conspicuous when the latter 
contains myomata. Carcinoma of the body is often overlooked unless 
the cervix happens to be dilated and the carcinoma can be felt directly 
with the finger. 

The diagnostic difficulties are •^ell illtistrated in the following twelve cases of myoma 
complicated by cancer of the body, which have come under my obser\'ation. 

Four cases were not recognized at all before operation. 

In two cases a timely diagnosis was made because the cervical canal happened to be open. 

In four cases the diagnosis was made because carcinomatous tissue was unexpectedly 
foimd in the scrapings. 

In two cases the diagnosis was regularly made by curettage because the symptoms 
aroused the saspicion of carcinoma. 

Hence in only one-third of the cases the diagnosis rested on a secure basis. 

The danger of overlooking a cancer of the body may be avoided by 
bearing the possibility of cancer in mind whenever there are any symp- 
toms that deviate in the least from those of ordinary- myoma and 
resemble those of carcinoma. They are: hemorrhages during the meno- 
pause and after coitus; persistent serous discharge (see Chart III); 
severe pain localized in the uterus, particularly if it recurs at a definite 
time of the day TSimpson's pains). Whenever symptoms of this kind 
are present, carcinoma should be suspected and a curettage per- 
formed for a microscopic examination. It should be an invariable rule 
always to subject the scrapings to microscopic examination in cases of 
myoma, even if there is no suspicion of cancer. By following this 
rule cancer was discovered in one-third of my cases. If the cervix 
happens to be dilated, the body should always be examined for cancer 
by digital exploration. 

The complication with sarcoma is based on the presence of a corre- 
sponding degeneration in the myoma, which may occur in all of the 
varieties, in about 2 per cent, in subserous, about 4.5 per cent, in inter- 
stitial, and about 9 per cent, in submucous tumors. The diagnosis of 
this degeneration varies in the different forms. 

In submucous myoma the diagnosis of sarcoma is difficult 
because the symptoms are practically the same as those produced by 

19 



290 GYNECOLOGICAL DIAGNOSIS 

the myoma and the physical signs, which are available only when the 
cervix is dilated, do not differ sufficiently from the signs of simple sub- 
mucous myoma. If the consistency is soft and friable, and the structure 
of the tumor irregular and lobulated, sarcoma may be suspected. 

As an illustration of the dif&ciilties encoiintered in the diagnosis I may mention that 
I correctly diagnosed sarcoma in only one case out of eleven. In all of the other cases the 
diagnosis was made later by examining the extirpated polyps. 

The diagnosis is chiefly made by microscopic examination; with 
this difference, however, that owing to the absence of any suspicion of 
malignancy, the examiner does not procure some of the tumor before- 
hand for examination but has the examination made after the tumor 
has been removed for a submucous myoma. As sarcomatous degenera- 
tion is to be expected in 9 per cent, of the cases, it should be a rule to 
examine every submucous myoma microscopically after extirpation. 

The diagnosis of sarcomatous degeneration of an interstitial 
myoma is still more difficult because a tumor in this situation is 
not accessible to direct palpation and the material necessary for 
microscopic examination cannot be obtained. 

Among ten cases of sarcoma in an interstitial myoma I made a correct diagnosis of 
only one. In all the others the tumors were removed imder the impression that they were 
pure myomata and only later recognized as sarcomatous. 

Certain symptoms may arouse the suspicion of sarcoma: hemor- 
rhage during the menopause, irregular metrorrhagias (see Chart IV), 
intense pain in the tumor independent of menstruation, emaciation 
and loss of strength when they are not to be explained by hemorrhages 
or other symptoms. None of these symptoms is, however, absolutely 
characteristic. The diagnosis rarely finds support in objective signs. 
The consistency is practically unchanged or may be quite variable; 
in some cases hard, in others soft. The rate of growth is not perceptibly 
increased in sarcoma and, if it is noticed at all, it is much more often 
attributable to cystic degeneration than to sarcoma. Metastases may 
possibly aid the diagnosis, as, in one of my cases, in the inguinal glands. 
The diagnosis is necessarily uncertain except in very advanced stages 
of the disease. 

In subserous myoma the conditions are somewhat charac- 
teristic on account of the involvement of the peritoneal investment, 
which not infrequently leads to the production of ascitic fluid and the 
formation of broad adhesions with adjacent organs; but as these peri- 
toneal symptoms may also occur without sarcoma, the diagnosis must 
in addition be supported by the other symptoms described in connection 
with interstitial myoma, particularly the general symptoms. 



I Myoma 
Janu' 



Profuse.-. 

Large — 
Increased. 

Normal 

Diminished-. 
Scant 



5 10 i5 



II Myoma 



Octo I October I November | December \ Januarij 

Profuse I- ' " '^ ' 



Large. 

IncreasecL- 
Normal 



Diminished 

Scant. 





III Myoma . 




r Myoma uiterstitiale with menorrhagia alone. 




JI Myoma submucosiim with menorrhagia and metrorrhagia. 




Ill Myoma interstitiale later complicated by carcinoma of the corpus uteri. At Grst simply menorrhagia ; and later also carcinomatous hemorrhage 




IV Myoma interstitiale later undergoing sarcomatous degeneration. At £rst simply menorrhagia ; latei also metrorrhagia. 




^ Myoma uteri interstitiale with total necrosis. At Srst simply menorrhagia; later, hemorrhage due to puerperal involution, and finally metrorrhagia due to total necrosis. 



Mmt. 


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SPECIAL DIAGNOSIS 291 

Among the benign degenerations the most important is total 
necrosis of an interstitial myoma, because it is attended with pronounced 
symptoms and may endanger the patient's life if the tumor is not 
removed in time. 

The total necrosis which occurs in submucous myomata during parturition and in 
subserous myomata when the pedicle becomes twisted is merely secondary to these processes 
and requires no separate discussion. 

Total necrosis of an interstitial myoma produces certain charac- 
teristic clinical symptoms which have a diagnostic value. The presence 
of a dead body in the uterine wall gives rise to reflex labor pains, which 
have for their object the expulsion of the body. They manifest them- 
selves as severe, intermittent pains localized in the uterus and extending 
over a period of weeks or months. Along with, and sometimes coinci- 
dent with the pains there may be hemorrhages, entirely irregular and 
independent of the menstrual type, and extending over days or weeks 
(see Chart V). If the process of elimination proves successful and the 
myoma is expelled into the uterine cavity, decomposition may set in in 
the myoma with the production of characteristic symptoms and septic 
fever. Absorption of the albuminous products of degeneration which 
are formed in the dead myoma sometimes gives rise to symptoms of 
intoxication — a grayish color, coated tongue, headache, nausea, vertigo, 
and flaccidity of the muscles (Freund, Sr.). Occasionally, but not always, 
acetone is found in the urine. As total necrosis occurs most frequently 
during parturition and in the puerperium, the statement that the above 
described symptoms have developed at the end of the puerperium is 
sometimes of diagnostic value. 

The information obtained by objective examination is of no value, 
as total necrosis produces no change either in the consistency or in the 
size of the tumor. While expulsion toward the cavity is in process, 
however, the necrotic myoma may occasionally be felt directly through 
the uterine wall. In short, the diagnosis is based on the clinical picture 
as a whole and, as the symptoms are quite marked, a correct diagnosis 
is very often made. 

The commonest of all degenerations that occur in myomata is 
undoubtedly a softening of the tumor due to accumulation of fluid 
in the tissue. If the extravasation of large quantities of blood can be 
excluded, the occurrence of clinically demonstrable softening can be 
attributed, as a rule, to the accumulation of lymphatic fluid, rarely 
in dilated lymph-vessels, more frequently in the lymph-clefts, and due 
either to stasis or to degenerative processes. 

The early stages of softening cannot be recognized because the 
quantity of fluid is too small. Even after small, multiple cavities have 
formed in the myoma, the organ usually retains its original consistency; 



292 GYNECOLOGICAL DIAGNOSIS 

if, however, large cavities are present or the myomatous tissue is more 
or less completely replaced by myxomatous material, the softening can 
be distinctly demonstrated by the fact that the myoma is more impres- 
sible and by a kind of spurious fluctuation. Solitary cavities contain- 
ing fluid may also escape palpation if they are still surrounded by a 
thick hard mantle of myomatous tissue; but if the cyst approaches 
the periphery or the surrounding mantle is soft, distinct fluctuation 
can be felt. Cystic degeneration may be simulated if the myoma con- 
tains but little connective tissue, or is covered by a very thick mantle 
of muscle tissue, or if the tumor is very vascular. 

Occasionally a myoma undergoes a sudden and very rapid increase 
in size as the result of an accumulation of fluid; these are cases in which 
a hemorrhage is followed by a copious effusion of fluid in the tissue. 
In all other cases, in which the process is rather one of substitution 
of myomatous tissue in process of degeneration by fluid, the size of 
the myoma remains constant or increases very slowly. Hence rapid 
enlargement is not a positive sign of softening. 

The diagnosis of softening has no special value, as it adds nothing 
to the severity of the condition and does not necessitate a different 
treatment. 

The clinical diagnosis of adenomyoma is not without some impor- 
tance, because these tumors differ somewhat from the ordinary myomata 
both in respect to the symptoms and the indications for treatment. 
The two varieties of adenomyoma, those which arise in the uterine 
mucous membrane and those which are derived from the Wolffian body, 
cannot be distinguished clinically. In these cases there is often a 
history of tuberculous taint, delayed puberty, frequent attacks of 
dysmenorrhea, sterility, violent pain, hemorrhages and bladder symp- 
toms. Objective examination in the case of adenomyoma derived from 
the Wolffian body reveals the tumor in the posterior wall near the 
fundus or at the tubal orifices. The signs of infantile uterus and vagina, 
i.e., small anteflexed uterus with contracted cervix and short narrow 
vagina (Freund, Sr., v. Rosthorn), are often present. Polano found peri- 
metritic adhesions in 89.5 per cent, of the cases. With the knowledge 
at present at our disposal a positive clinical diagnosis of adenomyoma 
is practically impossible. 



SPECIAL DIAGNOSIS 293 



Diagnosis of Ovarian Tumors. 

The term ovarian tumors is applied to a series of degenerative 
conditions and new formations of the ovary, the most prominent cUn- 
ical property of which is enlargement of the organ. Swelling of the 
organ, it is true, occurs also under normal circumstances, 
as, for example, from retention of fluid in a Graafian follicle 
and the formation of the corpus luteum, or it may be due to inflammatory 
conditions of the ovarian tissue, either acute or chronic. But the above 
conditions usually lead to an enlargement no greater than about half 
the size of an egg, which may accordingly be taken, in the main, as the 
boundary between transitory physiologic or inflammatory swelling, and 
permanent tumors; although it must also be emphasized that the 
former, in rare cases, may be somewhat larger, and the latter in their 
early stages occasionally smaller than the above mentioned standard. 
Accordingly I propose, from the diagnostic standpoint, to include 
among ovarian tumors all enlargements of the ovary exceeding the 
size of an egg. They include: 

A. Non-proliferating cysts (follicular cysts, cysts of the corpus lu- 

teum). 

B. Neoplasms. 

I. Parenchymatogenous tumors (parenchyma = germ epithe- 
lium, follicular epithelium and ovum). 

1. Epithelial neoplasms. 

(a) Cystoma serosum simplex. 

(b) Cystadenoma. 

(a) Cystadenoma pseudomucinosum. 
(o) Cystadenoma serosum. 

(c) Carcinomata. 

2. Ovigenous neoplasms. 

(a) Dermoids 1 /-r. i - n 
\\ rr . . y (Embryomata). 

(b) ieratomataj 

II. Stromatogenous tumors. 
Fibromata. 
Sarcomata. 

Peritheliomata and endotheliomata. 
Combinations of these different varieties of tumors frequently occur. 

Diagnosis and Differential Diagnosis of Ovarian Tumors. 

The ovarian tumor is connected to the uterus by a pedicle, and a 
knowledge of this peduncular connection is of great importance for the 
diagnosis. The pedicle contains the same elements that connect the 



294 



GYNECOLOGICAL DIAGNOSIS 



normal ovarj^ with the uterus, i.e., ovarian Ugament, tube and broad 
ligament (Fig. 151). The ovarian ligament retains its original shape 
Anatomy of more than anj' other part of the pedicle; although it is 
the Pedicle. occasionally drawn out lengthwise it retains its thickness 
and firmness, and is that part of the pedicle that represents the pal- 
pable, cord-like connection of the tumor with the uterus. The tube may 
vary considerably in length; sometimes in very large tumors it may 




Fig. 150. — Bilateral Malignant Ovarian Tumors in situ. (Specimen from the Kgl. Universitats- 
Frauenklinik in Konigsberg.) (Original.) The uterus is situated in the middle and gives off a pedicle on each 
side to the tumor ; the pedicle shows the three component parts : in the middle, the ovarian ligament ; later- 
ally, the infundibulo-pelvic ligament ; and between the two, the tube. The round ligament runs along the 
lower surface of the uterus. 

retain its normal length; in another case it may be greatly elongated 
even with only moderately large tumors. The length of the tube de- 
pends on the relation between the tumor and the mesosalpinx. The 
more the tumor develops independently of the mesosalpinx and the 
broad ligament, the smaller will be the part taken by the tube in the 
formation of the pedicle; and the more the tumor approaches the tube 
by unfolding of the mesosalpinx, the greater will be the elongation of 
the tube by the growth of the tumor. The broad ligament, with the 
vessels, nerves and connective tissue contained between its two layers, 
represents the greater part of the true pedicle, the lateral free border 



SPECIAL DIAGNOSIS 



295 



of which is formed by the infundibulo-pelvic ligament. The broad 
ligament may be completely preserved in length and breadth if the 
tumor is j^edunculated and grows only outward; in that case only the 
mesovarium and a small part of the mesosalpinx are unfolded, and 
assist in forming the covering of the tumor (Fig. I523). The length of 
the pedicle varies greatl}^; sometimes it is so short that the finger can 
barely be inserted between the tumor and the uterus, or its length may 
be such that the tumor can be pushed under the arch of the ribs. The 
width is also subject to great variations. A peculiar condition is 
often found in solid tumors produced by a uniform degeneration of the 
ovary; the layers of the mesovarium are not separated and are 





Fifi. 151. — Relations of the Pedicle in a Nokmal Ovary and in an Ovarian Tumor. (Schematic.) 
(Original.) The pedicle is formed by the tube, ovarian ligament and broad ligament ; the base of the tumor 
only is covered by the unfolded mesovarium. 

drawn into the hilus of the tumor so that the latter projects beyond 
the pedicle in all directions, and thus renders' the pedicle very short 
and rigid (Fig. I522). 

If the ovarian tumor grows toward the mesovarium and broad 
ligament, it crowds the two layers of the latter apart and pushes in 
betw^een them. In this way it is completely or partially covered with 
the peritoneum of the broad ligament and becomes an intraligamentary 
tumor (Fig. 152J. Most ovarian tumors exhibit a partial lutraiigamen- 
development into the broad ligament, in such a manner that *^''^' ^^®" 

a small part of the base of the tumor is lodged between the layers of 
the mesovarium and the broad ligament, and the remaining peripheral 
part develops free. Intraligamentary development is seen most dis- 
tinctW in parovarian tumors, which usually occupy the lateral portion 
of the broad ligament, do not separate the layers of the median portion, 
and draw it out into a kind of pedicle. 



296 



GYNECOLOGICAL DIAGNOSIS 



An intraligamentary ovarian tumor may grow in various directions. 
It may leave the outer portion of the broad hgament and grow into 
the retroperitoneal connective tissue to the left, underneath the sig- 
moid flexure, and to the right under the cecum. Other tumors elevate 
the posterior layer of the broad ligament and thus reach the posterior 
pelvic wall, or grow into the loosely attached peritoneum of the pos- 
terior uterine wall, and reach the other side; or — much more rarely — 
they may elevate the anterior layer, and appear in the neighborhood 
of the bladder, in the preperitoneal cavity of Retzius. In most 
cases intraligamentary ovarian tumors cause a separation of the 




Fig. 152. — Relations or Ovarian Tumors to the Broad Ligament in Sagittal Section. (Sche- 
matic.) (Original.) 1. Normal ovary. 2. Short pedicle in solid tumors. 3. Ordinary pedicle of ovarian tumors. 
4. Intraligamentary type. 5. Retroligamentary type. 

median portion of the broad ligament and grow toward the 
uterus, crowding up close to the lateral aspect, and sometimes even 
separating the uterine muscle. In such a case they may be situated in 
the true broad ligament alongside of the body, or they may develop 
farther down in the parametrium alongside of the cervix, and occupy 
a position on the vaginal vault. 

A situation similar to that of an intraligamentary tumor inay be 
seen when an originally pedunculated ovarian tumor is held fast by 
adhesions on the floor of Douglas' space and prevented from growing, 
Retrohgamen- upwarcl. The tumor in that case elevates the broad liga- • 
tary Type. mcnt which covers it, so that the posterior and upper parts 

of the tumor project free into the abdominal cavity, while in front it is 
covered by the two layers of the broad ligament, either free or adherent 



SPECIAL DIAGNOSIS 



297 



to the tumor; the tube runs along the upper border of the broad hga- 
ment over the top of the tumor. This type is called retroligamentary 
(Pawlik's pseudointraligamentary type, Fig. 152g). 

Ovarian tumors, so long as they are small, are usually approxi- 
mately round or oval, and may retain this shape as they continue 
to enlarge if the tumor consists in the main of a single cyst. If, how- 
ever, several or many cysts take part in the formation of the tumor, 
it becomes irregular and shows retractions, deep divisions, protu- 




FiG. 153. — Ovarian Cyst AND Parovarian Cyst OF THE Same Side. ^. (Original.) (Specimen from 
the Kg!. Universitiits-Frauenklinik in Konigsberg. ) The ovarian cyst hangs by a pedicle from the broad 
ligament, between the layers of which a small parovarian cyst has developed. A probe has been passed 
through the tube. 

berances, and tubercles, depending on whether the individual cysts 
appear on the surface, or the solid portions of the tumor are more 
conspicuous. A solid tumor may, if its growth is uniform, have an 
absolutely round or oval shape; others, particularly malig- 
nant tumors, owe their enlargement to irregular proliferations 
of the superficial tissue. The size of the tumor varies within very wide 
limits, ranging from enlargements the size of an egg, which barely 
deserve the name of tumor, to an enormous size, distending the abdom- 
inal walls to their utmost, pushing the diaphragm upward, causing 
incurvation of the costal arch, and filling the entire abdomen to such an 
extent that the rest of the body becomes smaller than the tumor. The 



Shape. 



298 GYNECOLOGICAL DL\GNOSIS 

consistency of ovarian tumors is by no means uniform; tumors filled 
with fluids are cystic, while those consisting only of parenchyma or 
stroma have a solid consistency. This general statement is, however, 
subject to many qualifications, not so much that solid tumors may 
have a cystic feel on account of softening as that tumors distended 
with fluid often do not exhibit fluctuation. This is the case in small 
cysts containing moderate quantities of fluid with high internal press- 
ure and tense walls; and cystadenomata containing numerous small 
cysts or colloid material. Pedunculated tumors are movable unless 
they encroach to such an extent on the abdominal cavity that there 
is no longer room for movement; on the other hand, ovarian tumors 
may become immovable by reason of incarceration in the true pelvis, 
adhesions with neighboring organs, or intraligamentary development. 
The relations to neighboring organs, especially to the uterus, may be 
various; so long as the tumors are small they occupy the site of the 
ovary; as they increase in size, however, and particularly if the liga- 
ments are relaxed, they usuall)- descend into Douglas' space; more 
rarely they lie in front of the uterus. In their subsequent growth the 
tumors emerge from the pelvis and approach the anterior abdominal 
wall, forcing the uterus downward or backward. From this time on 
they remain constantly in contact with the anterior abdominal wall and 
gradually become more and more distended. 

It appears, therefore, that with regard to shape, consistency, 
movability, seat, and connection with neighboring organs, ovarian 
tumors produce such a variety of clinical pictures that it is difficult to 
define any general or constant properties which might afford a basis 
for diagnosis. The latter is based practically on the palpation of 
a peduncular connection between the tumor and the uterus. The method 
of arriving at a diagnosis differs very much, however, according to the 
size of the tumor, and for this reason it is advisable to subdivide ovarian 
tumors for diagnostic purposes as follows: 

1. Small ovarian tumors still occupying the true pelvis. 

2. Medium-sized tumors which have emerged from the pelvis and 
appear in the abdominal cavity, but do not much exceed a man's head 
in size, and certainly have not yet reached the costal arch. 

3. Large tumors extending to the costal arch and in direct contact 
with the liver, spleen and kidneys. 

Aside from the difference in the methods of arriving at a diagnosis 
in these three groups, the classification has the further advantage that 
the differential diagnosis must take into consideration very different 
conditions, depending on the size of the tumor. (Many tumors such as 



SPECIAL DIAGNOSIS 



299 



myomata may, depending on their size, be mistaken for ovarian tumors 
belonging to any one of these three groups; but in order to avoid repe- 
tition, the differential diagnosis will be discussed only once in connection 
with the conditions with which they are most likely to be confounded.) 

1. Small Tumors. 
Diagnosis. In the case of small tumors that still occupy the true 
pelvis it is usually not possible to demonstrate a peduncular connec- 
tion with the uterus; for the uterus and the tumor are usually so close 
together that the finger cannot 
be inserted between them, or the 
pedicle is not sufficiently stretched 
to permit palpation. Artificial 
stretching of the pedicle, which is 
performed in the case of large 
tumors, is not practicable on 
account of the small size and lim- 
ited mobility, and hence it is 
only occasionally possible to pal- 
pate the pedicle by pushing the 
tumor into the false pelvis and 
palpating between it and the 
uterus; in retro-uterine tumors 
also a cord can sometimes be felt 
running to the anterior surface 
of the tumor. But such cases 
are exceptional; in the great ma- 
jority of small tumors this text- 
book sign is not available, and 
they must be identified as ovarian 
by their special peculiarities. To 
begin with, one should try to separate the tumor from the uterus 
(Fig. 154); either the tumor can be completely separated from the 
uterus, as in the case of pedunculated tumors, or, if the tumor develops 
between the layers of the broad ligament, it should be 
possible to make out a distinct constriction between the 
tumor and the uterus. The nearer the tumor lies to the uterus, the 
more difficult it will be to make out this constriction, and in some 
cases it can be done only by attempting to go in between the two 
through the vaginal vault alongside of the vaginal portion; above, 
at the uterine body, the two frequently form a single mass. Retro- 
uterine tumors are particularly difficult to separate from the uterus 
if the tumor is firmly incarcerated and in extensive contact with 




Fig. 154. — Right-sided Cystic Ovakian Tumor 
(from a preparation in the Kgl. Universitats-Frauen- 
klinik in Berlin). '/i. (Original.) Douglas' space 
contains a movable, round cystic ovarian tumor of the 
right side, which has crowded the uterus to the left 
and forward. In front of it is the bladder ; part of 
the right tube can be .seen in front of the tumor ; the 
left adnexa are normal. 



Diagnosis. 



300 



GYNECOLOGICAL DIAGNOSIS 



the posterior wall, or intimately attached to the wall by adhesions and 
exudates; but even under these circumstances the examiner should 
attempt to separate the round contour of the tumor from the uterus 
and to exclude any peduncular connection, such as belongs, to myomata 
and tubal tumors. The shape of an ovarian tumor is approximately 
globular or oval; the surface is usually smooth and sometimes retracted 
at various points (Fig. 155). Lobulations and protuberances are found 
in solid tumors, and occasionally also in dermoids. The cystic consist- 
ency of small ovarian tumors is usually not recognized; as a rule, they 
give the impression of a solid tumor on account of the great tension of 
their walls and the small amount of contents, particularly when the 
walls are thick; thin, solid, flabby tumors are more easily recognized 




Fig. 155. — Left-sided Ovarian Tumor. P.-F. %. (Original.) Follicular cyst of the left ovary 
the size of a goose-egg, with dextro-position of the uterus. The entire length of the left tube is distinctly felt 
in front of the tumor. The right ovary is normal. 

as cystic. It is only by grasping the tumor firmly between the fingers 
and making forcible but cautious pressure at opposite points that 
fluctuation can be elicited. Solid ovarian tumors of this size are much 
more rarely seen. The position of the tumor at once points to an ovarian 
origin. If it is found at the site of the ovary, we need not hesitate under 
such circumstances to pronounce it an enlarged ovary. Small ovarian 
tumors are most frequently found posteriorly, alongside the uterine 
body, or they descend into Douglas' space and form a retro-uterine 
tumor with anteposition of the uterus. Intraligamentary tumors 
are situated exactly to one side, and somewhat behind the uterus. 
Movable ovarian tumors are more rarely found in front of the uterus 
than any others. Among these anteuterine tumors, dermoids are 
conspicuous b}' their frequency. 

Differential Diagnosis. The first difficulty encountered in the 
interpretation of these small ovarian tumors is in distinguishing 



SPECIAL DIAGNOSIS 301 

them from inflammatory swelling of the ovary. In chronic 
oophoritis the ovary, it is true, rarely exceeds the size of a pigeon's egg 
and is distinguished from true ovarian tumors by its great 
sensitiveness to pressure, and occasionally also by the pres- Diagno^s^lof 
ence of complicating inflammatory processes in the neigh- ^""ooph^S 
borhood. Acute oophoritis, on the other hand, may lead to 
the formation of larger tumors. As a rule the fever, the extreme tender- 
ness, the accompanying pelvic peritonitis, and the history or the presence 
of an infection as the cause, will indicate the correct diagnosis. The diffi- 
culties of this differential diagnosis are illustrated by the following case: 

Case 2.3. A patient, 21 years of age, had been curetted twenty-six days previously 
and three days later developed fever up to 40.4° C. (104.7° F.;, with chills. There 
was found to the left and behind the small anteflexed uterus, in Douglas' space, an 
apparently solid ovarian tumor quite as large as the fist. As it was entirely painless and 
movable it was regarded as a dermoid cyst. On extirpation, however, it was found to be an. 
ovary enlarged as the result of edematous infiltration, with an abscess a little larger than a wal- 
nut ; there were no signs of inflammatory redness on the surface or in the surrounding tissues. 

The differential diagnosis between ovarian tumors and my o mat a 
is important, and often very difficult to make. The two neoplasms are 
often mistaken for one another even by the most practiced diagnos- 
ticians, because they have certain properties in common. If the exam- 
iner depends on one of these properties without taking the picture as a 
whole into consideration, he runs a great risk of making a false diagnosis. 
The palpatory findings alone should form the basis for diagnosis. Symp- 
toms are of no value whatever in arriving at a decision; the develop- 
ment of the tumor at an early stage is, of course, in favor of ovarian 
tumor, but it is not a reliable factor, just as the appearance and growth 
of a tumor after the menopause merely excludes myoma with a certain 
degree of probability. Very rapid growth is in the main more in favor 
of an ovarian tumor, while a slower development points to myoma. A 
positive conclusion, however, must be arrived at by bimanual exami- 
nation. It is obvious that subserous myomata with rather thin pedicles 
are most apt to be found with ovarian tumors. Interstitial myomata, 
while small, are easily recognized; but if they form large tumors they 
may also be occasionally mistaken for ovarian tumors, and vice versa. 
The most important point of distinction is the consistency. It may 
almost be stated as a general principle, that solid tumors are myomata 
and cystic tumors ovarian, although myomata may, as a result of 
various conditions, become so soft that they exhibit fluctuation; while, 
on the other hand, solid ovarian tumors are not so very rare, and even, 
cystic ovarian tumors may be very hard to the touch, as, for example, 
thick-walled dermoid cysts and parvilocular cystomata. But these are 
all exceptional conditions, and while they may limit the scope of the 
above general statement, they are not sufficient to invalidate it. A 



302 GYNECOLOGICAL DIAGNOSIS 

cystic consistency is always the main support of a diagnosis of ovarian 
tumor. The diagnostic errors, which not infrequently rest on a 
misinterpretation of this property, are due not so much to incorrect inter- 
pretation of a correctly recognized consistency, as to mistakes in obser- 
vation, the consistency not being correctly recognized. If the abdominal 
wall is thick, and coils of intestine are in contact with it, or if the tumors 
have thick walls, it is difficult to estimate the consistency. The best 
method consists in grasping the tumor with both hands at two as nearly 
opposite points as possible, and compressing the tumor by a series of 
short pushing movements. If the tumor is seated deep in the pelvis 
it is unquestionably easier to test the consistency by examining through 
the rectum. After the consistency of the tumor has been demonstrated, 
its connection with the uterus must be investigated. Pedunculated 
ovarian tumors have only a thick, membranous pedicle which either 
cannot be felt at all, or may just be recognized by the ovarian ligament 
when the uterus is^forcibly drawn downward. Myomata, on the other 
hand, usually have a pedicle which is much thicker than the ovarian 
ligament, shorter, with a more fleshy feel, broader and more distinct; 
although they also occasionally have only a very thin pedicle. If the 
pedicle is joined to the fundus or some other portion of the body where 
the uterine ligament cannot be inserted, the tumor is probably a myoma. 
Another point in favor of myoma is the failure to identify the tube as 
part of the pedicle. The best method of palpating the pedicle is that 
proposed by Schultze and Hegar (see page 305). The examination is 
much more difficult when the abdominal walls are thick, and the organs 
to be palpated deeply situated. The difficulties of making out a pedun- 
cular connection are still greater in intraligamentary tumors. As a 
rule, these ovarian tumors grow only toward the uterine wall, so that a 
constriction can everywhere be distinctly demonstrated; while myomata 
always have a fleshy connection with the uterus, although in very rare 
cases an intraligamentary myoma may be completely separated from 
the uterine wall. It may, however, be very difficult to isolate the 
uterus if, as is often the case in senile women, the organ is flat and 
long-drawn-out and in close contact with the tumor. On the other 
hand, ovarian tumors may have such a vigorous growth that they force 
the uterine wall apart and create a covering of muscle for themselves 
at this point, representing tumors with a broad connection with the 
uterus, like broadly sessile, subserous myomata. 

Case 24. Mrs. H. Uterus in correct elevation ; to the right, a tumor as large as a 
child's head ; to the left, another as large as a man's head, with an extensive attachment 
to the uterine wall. Nine months ago a diagnosis of subserous myoma was made by one of 
the first gynecologists in Germany. At the present time, in spite of the broad connection 
with the uterus, a positive diagnosis of bilateral ovarian tumor can be made, because the 
consistency is everywhere distinctly cystic. At the operation both tumors had to be peeled 
out of the uterine wall with a knife, leaving a wide depression on each side of the organ. 



SPECIAL DIAGNOSIS 303 

Mensuration with the sound plays an important part in the 
differential diagnosis between myomata and ovarian tumors, inasmuch 
as there is always a certain increase in the length of the cavity with 
myoma — with the exception of myomata that have very thin pedicles 
and a uterus everywhere free from myomata — whereas, in the case of 
ovarian tumors the length of the cavity is not as a rule increased. 
Nevertheless, in the case of rapidly growing intraligamentary ovarian 
tumors a thin uterus may be drawn out to such an extent that the 
sound yields a measurement of 10 to 12 cm. The detection of the adnexa 
by palpation may occasionally decide in favor of myoma in doubtful 
cases, provided the two normal ovaries can be felt beyond the possibility 
of a doubt; as a rule, however, this is not possible, because in the case of 
subserous myomata the ovaries are displaced to such an extent that 
they are not accessible to palpation. The round ligaments are very 
welcome signs, pointing to interstitial myoma if they can be traced up 
over the dome of the tumor. In subserous myomata they do not have 
such diagnostic value because they do not necessarily pass over the 
tumor. In intraligamentary myomata and ovarian tumors the behavior 
of the round ligaments may be identical, because the ligament in the 
case of every tumor developing in the lower portion of the broad 
ligament passes obliquely over the tumor toward the anterior layer 
and ends in the fundus. A distinct uterine bruit may occasionally 
serve to clinch the diagnosis of myoma as against ovarian tumor. 

Special difficulties are encountered in the differential diagnosis 
between intraligamentary ovarian tumors and other kinds of tumors 
developing in the same manner, because the broad ligament loses its 
characteristic properties by its investment with connective 

. _ _ , Intraligament- 

tissue and peritoneum, and its connection with the uterus ary ovarian 
is particularly difficult to palpate. Tumors of this kind 
are: tubal tumors, hematomata and exudates. Small, multilocular, 
papillary tumors are particularly difficult to recognize because fluctua- 
tion is not distinct, and their round shape is obscured by the numerous 
projecting divisions and the often inflamed and thickened ligament 
which covers them. Exudates are distinguished by their diffuse shape, 
rarely round, hard consistency, and broad connection with the pelvis. 
Hematomata have a greater resemblance to ovarian tumors because 
they are more round and of soft consistency. They are distinguished 
from ovarian tumors, however, by their irregular shape and the zone of 
reactive infiltration in the surrounding connective tissue, especially 
in the case of older tumors. By keeping the patient under observation 
for a time many a doubt may be cleared up; for exudates and 
hematomata gradually disappear, while ovarian tumors continue to 
grow. Intraligamentary tumors, whether tubal or ovarian, are often 



304 



GYNECOLOGICAL DL^GNOSIS 



indistinguishable by any diagnostic method. (For the details see 
chapter on Parametritis and Diseases of the Tubes.) 

For the differential diagnosis from hydrosalpinx, see the latter. 

When the tumor is situated behind the uterus (Fig. 156) it may be 
confused with a retro-uterine hematocele or pelveo-peritonitic exudate 
— conditions which may be distinguished from one another by certain 
definite points, while, on the other hand, they possess certain common 
properties which place them in the same class as against ovarian tumors. 




Fig. 156. — Retro-dterine Ovarian Tumor. P.-F. 3^. (Original.) An ovarian tumor the size of a small 
man's head ; uterus in anteposition ; tumor and uterus can be wholly separated from one another. 

(For the differential diagnosis see pelveo-peritonitic exudate.) There 

is less likelihood of confusion with retroflexion of a gravid uterus because 

the consistency of the gravid uterus alone is quite different, although 

it must be admitted that an incarcerated uterus at the 

Retro-uterine 

Ovarian beginning of the third or fourth month may lose its 

characteristic softness and develop a tense consistency 
similar to that of an ovarian tumor. As a rule, the diagnosis of 
retroflexion of a gravid uterus can easily be made by determining the 
junction between the vaginal portion and the uterus; and if it is not 
possible, the above mentioned signs of pregnancy, the history, and 
observation of the patient must be utilized in making the diagnosis. 



SPECIAL DIAGNOSIS 305 

2. Medium=Sized Tumors. 
Diagnosis. The demonstration of a tumor in such cases usually 
presents no difficulty. The conical protrusion of the abdomen renders 
its presence probable, and by means of percussion and palpation it can 
usually be demonstrated beyond a doubt. With tumors of 

• 1 T f 1 • I'll Diagnosis. 

this Size there is less danger of being deceived by an accu- 
mulation of fat or meteorism, which may simulate a tumor, than in the 
case of very large neoplasms, because these conditions cannot be lim- 
ited to a circumscribed portion of the abdominal wall. If the existence 
of a tumor has been positively demonstrated, its position at the pelvic 
inlet will at once suggest its origin in the genitalia, while the demon- 
stration of a distinctly cystic consistency will point to the ovary. But 
in these tumors also the chief point in the diagnosis is the demonstration 
of a connection with the uterus — the feeling of a pedicle. The distinct- 
ness with which the pedicle can be demonstrated will depend on its 
position and the firmness of the component tissues. In order to feel 
the pedicle the external hand, with or without the internal hand, is 
pushed down between the cornu of the uterus and the tumor. When 
the uterus is anterior and in front of or underneath the tumor, and the 
pedicle is firm, the latter can be felt merely by passing the fingers of the 
external hand to and fro in a direction vertical to the course of the 
pedicle, but not under any other circumstances; in most cases, how- 
ever, the pedicle is too flabby or too far away from the abdominal walls 
to be palpated with certainty from the outside. Palpation is most diffi- 
cult when the uterus is behind the tumor. In the great majority of the 
cases a special method of examination is therefore necessary in order to 
demonstrate the pedicle with certainty. This consists in stretching the 
pedicle artificially by grasping the vaginal portion with a double tenacu- 
lum and drawing the uterus forcibly downward (Hegar). Internal exam- 
ination must in that case always be made per rectum because vaginal 
exploration is impossible on account of the inversion of the vagina 
which accompanies the drawing down of the uterus. The patient should 
be anesthetized, and two fingers introduced as high as possible into the 
rectum, while the external fingers are passed to and fro between the 
cornu of the uterus and the tumor in a direction perpendicular to the 
course of the pedicle. Demonstration of the pedicle may be rendered 
easier by having the assistant force the tumor upward (Schultze), and 
bring down with the external hand as much of the abdominal wall as 
possible, so as to press the hand deep down into the abdomen (Fig. 
157). In most cases demonstration of the pedicle serves to show at the 
same time from which horn of the uterus it originates, and thus indicates 
which side the tumor belongs to. This part of the diagnosis may be 
confirmed by the demonstration of a sound ovary on the other side 
20 



306 



GYNECOLOGICAL DIAGNOSIS 



mid llic I'c'uly inovn.bilil y <>l Hie oilier conin of llic uterus, while the 
coriur on (lie (lincuscd side is more or less lixcd by Uic sliort. pedicle. 




h. !,: (u 



111. 






■C O 3 
O " t 



5! w ,^ 

S "^ s 
h2 S 



■' 2 ° 
•-a -=i 

g 1 






0) .i:* 



! - fc 

> X J- 
, ^ -a 

C-T3 



ii ^ 
js S 



Positive^ demonslralion of a pcMlieU^ is llu^ b(\'^(. prol(M*tion against 
diai;iu)sii(' luistakcs. lii senile, atrophic cases 1 hav(> sometimes failed 
to recognize the pedicle on account of the tenuity, of the tissues. 



SPECIAL DIAGNOSIS 307 

DifFicultios arise when the ix'didc is so sliort lli.'it ll)(> liaiid cannot 
be introduced between tli(> uteinis and tlie tumor, or when adhesions 
connect the two, or the tumor has developed between tlic; hiyers 
of tlie broad ligament. In su(di cases an attempt should be made 
at least to isolate the tumor from the utei'us and to base the diagnosis 
on the general characteristics of tlu! tumor, particularly its shape 
and c()nsist(>ncy. 

Th(> differential diagnosis of these medium-sized tumors embraces 
a larger lieid than lliai of tli(! smaller neoplasms that still occupy the 
pelvis, because tumors of individual abdominal organs and Differential 

of the abdominal walls must also be considered. The uiagnows. 

foundation of the differential diagnosis in every instance must be the 
d(>monstration of a ])edicle, and next in importance are the properties 
of the tumors, which may aid in arriving at a decision. 

Dif f (!rential diagnosis from encapsulated ascites or 
peritoneal exudate. While free ascites rarely produces sufficient 
tension of the abdominal walls to be confounded with ovarian tumors — 
and in any case only with very large ones — encapsulated 
ascites may, on the other hand, form a circumscribed tumor reritoneai 

of cystic consistency. In peritoneal diseases, such as 
chronic inflammatory conditions, a quantity of fluid frequently becomes 
encapsulated between the intestinal coils and the anterior abdominal 
wall. These collections of fluid may by their cystic consistency 
resemble an ovarian tumor, such as a multilocular cyst, which may be 
simulated by the presence of metastatic or inflammatory thickening in 
the neighborhood. The distinction between these tumors and ovarian 
neoplasms is difficult because, owing to the general adhesions, the 
uterus cannot well be isolated, and it is never possible to feel a pc^dich;; 
on the other hand, their shape and boundaries are often ({uitc distinc- 
tive. In ovarian tumors, even when they are thin, solid, and sur- 
rounded by adhesions, it can be determined by palpation that the 
tumor is bounded by its own wall; whereas encapsulated exudates do 
not exhibit a round contour separating them from the intestines, but 
instead merge gradually with the surrounding inflamed and thickened 
tissues. The shape of encapsulated exudates is flat, rarely round or 
oval, and there is not much protrusion of the abdominal wall. Some- 
times the demonstration of nodules in the peritoneum, or of collec- 
tions of fluid encapsulated in other regions, establishes the diagnosis of 
peritonitis. The percussion note over ovarian tumors is distinctly 
dull, while encapsulated exudates, owing to the adherent coils of 
intestine, often give a modified tympanitic note. Occasionally the 
diagnosis of ascites may be made by the symptoms of peritoneal 
disease of long standing. 



308 GYNECOLOGICAL DIAGNOSIS 

Case 25. Mrs. N. Uterus small and in anteversion ; 6 cm. There is a tumor 
extending upward two fingers' breadth above the umbilicus and beyond the median line on 
both sides ; below it extends into the pelvis behind the uterus ; connection with the uterus 
is demonstrated with difficulty. As the tumor feels smooth, has a cystic consistency, and is 
moderately movable, it is regarded as an ovarian tumor. At the operation there was found 
underneath the omentum and between the coils of intestines an encapsulated tuberculous 
ascites with miliary nodules on the adjacent peritoneum. 

Tumors of the abdominal wall are apt to be confused with 

ovarian tumors only when the latter are broadly and closely adherent 

to the a,bdominal wall. The most important conditions to be con- 

, , sidered are exudates in the retropepitoneal connective 

Tumors of the , _ _ ^ 

Abdominal tissuc of the anterior abdominal wall, and fi'bromata of the 

Wall. . 

abdominal walls; both usually have a very hard consist- 
ency, which distinguishes them from cystic ovarian tumors. Further- 
more, even in the presence of firm adhesions, a round outline is always 
in favor of an ovarian tumor, whereas exudates are more flat and usually 
end above in a sharp edge, are lost below in the pelvic tissue, and have 
a broad surface of attachment to the uterus. A lateral position is more 
in favor of exudates; a median position, of ovarian tumors; even when 
extensive suppuration has destroyed the hard consistency of the exudate, 
the absence of a round contour is against a tumor. Fibromata of the 

abdominal walls originate either in the fascia of the internal 

Fibromata of _ _ 

the Abdominal obllquc or trausvcrsalis muscles, particularly at the crest of 
the ileum, or in the posterior layer of the sheath of the rec- 
tus. Fibromata originating in the latter situation are usually so small 
and so superficial that confusion with ovarian tumors is hardly conceiv- 
able; on the other hand, fibromata of the internal oblique represent 
larger tumors which, on account of their round shape, may resemble an 
ovarian tumor — of course, owing to their hard consistency, a firm 
ovarian tumor. If the tumor is cystic, it is probably not a fibroma of 
the abdominal walls, even if the situation is typical. If the tumor has 
grown outward and forms marked prominences, it is probably a tumor 
of the abdominal wall; if it is deeply situated and develops more toward 
the abdominal cavity, it may be assumed to be intra-abdominal. Occa- 
sionally a direct connection between the tumor and the abdominal 
muscles can be demonstrated by putting the abdominal walls on the 
stretch and elevating the patient; or, if the abdominal walls are flabby, 
it may be possible to grasp the tumor with both hands from behind. 
In all doubtful cases it is needless to say that the demonstration of a 
peduncular connection with the uterus, or the finding of two normal 
ovaries, is conclusive. 

Omental tumors may occasionally be confounded with ovarian 
tumors if they extend into the pelvis. They are, however, usually flat, 
resembling a shield, and are characterized by their great rotability in 



SPECIAL DIAGNOSIS :50!) 

various directions. In one case Bcuckisor was abl(^ to rotate an omental 
tumor so far upward tliat the posterior surface" could be felt. According 
to this author, it is always possible in cases of omental tumor to demon- 
strate a process going to the spleen. The absence of connection with 
the genitalia, in this case also, is against an ovarian tumor. 

A distended bladder may easily be mistaken for an ovarian 
tumor because the position, shape, contour and consistency all com- 
bine to produce a resemblance. The bladder, to be sure, is usually much 
more flabby, but it may become quite tense if it is greatly Distention of 
distended ; it is usually somewhat sensitive to strong press- ^^^ Bladder, 
ure. A distended bladder is not as freely movable as a pedunculated 
tumor, because when the organ is overfilled most of it is extraperitoneal. 
An error in diagnosis is usually made if there is no retention of urine, 
and the patient has dribbling instead, particularly if the walls of the 
bladder are thickened by chronic cystitis. One who lacks experience 
in diagnosis is advised to use the catheter in all doubtful cases. 

Echinococcus sacs are frequently mistaken for ovarian 
tumors, particularly if they occupy the pelvis and grow close to the 
uterus. Their similarity consists in the fact that they are also distinctly 
round and fluctuating; as a rule, however, they are much Echinococcus 
more tense, and their walls are thicker than those of ovarian ^^'^^' 

tumors; they also exhibit unusually thick adhesions with the surround- 
ing tissues. They are often multiple, and in that case appear in a situa- 
tion where no ovarian tumors could be present. Other points in favor 
of echinococcus sac are the combination with tumors of the liver, a very 
slow rate of growth and the statement that an operation has been 
performed at some previous time for the same disease. 

Case 26. Mrs. H. The uterus is in anteposition, and displaced to the left and 
forward by a tense tumor the size of a fist, situated to the riglit and behind the organ. The 
tumor can be differentiated from the uterus and has many adhesions with the surrounding tis- 
sues. Although the tumor gave the impression of an ovarian cyst, although no other tumors could 
be demonstrated in the abdomen, a diagnosis of echinococcus was made because the patient 
had already been operated on twice for the same disease. Operation confirmed the diagnosis. 

The difTerential diagnosis between ovarian tumor and preg- 
nancy represents a realm of extraordinarily frequent diagnostic errors. 
The number of cases in which the diagnosis of pregnancy was not defi- 
nitely made until the laparotomy is very considerable. 
The error is usually due, in the first place, to the patient's 
delusion that she is pregnant because of the increase in the size of the 
abdomen and supposed fetal movements. The physician, being un- 
certain in his mind, accepts the patient's theory, mistakes nodules on 
the tumor for fetal parts, and thinks he hears heart sounds. As the 
uterus cannot usually be outlined by bimanual examination, he mis- 



310 GYNECOLOGICAL DIAGNOSIS 

takes the entire tumor for the uterus. If, in addition, there happens 
to be intermittent or irregular menstruation, the mistake is even more 
easily made; but the fundamental cause of the error is the superficial 
examination for fetal parts and heart sounds. During the first half 
of pregnancy, when the fetal sounds are absent, mistakes of this 
kind are of course much more easily possible. They occur chiefly in 
cases with a markedly anteflexed gravid uterus in the fourth or fifth 
months, simulating an ante-uterine, roundish, soft and cystic, hence 
ovarian tumor, because it is not easy to decide whether the vaginal 
portion, which is displaced far backward, merges with the tumor or 
with the uterus which lies behind the tumor; a marked softening of the 
lower uterine segment is responsible for this mistake. It is only by 
examining high up in the rectum, or passing the fingers along the 
lateral wall of the cervix to the uterine body, that it is possible 
to confirm or exclude junction of the vaginal portion with the tumor. 
In other cases it is an intraligamentary ovarian tumor with a broad 
attachment to the uterus that simulates uniform enlargement of the 
. organ and, owing to the cystic consistency, suggests the tumor of preg- 
nancy. In the third and fourth months the conditions are particularly 
favorable for such a mistake. In such cases it is not always safe to 
assume the presence of a tumor alongside of the uterus if the vaginal 
portion merges, not with the middle, but with the lateral aspect, as this 
also occurs in pregnancy with irregular protuberances of the body and 
with lateral deviation. The difference in the consistency between the 
hard uterus and the cystic intraligamentary tumor may also be 
observed in a similar manner when the softening of the pregnant uterus 
is irregular; on the other hand, the sign of mobility of the uterus on 
the tumor is much more reliable. If the two ovaries can be palpated, 
and the junctions of both round ligaments with the tumor are demon- 
strable, pregnancy is of course definitely established. With regard to 
the value of the history in this differential diagnosis, the reader is 
referred to what has been said under the head of pregnancy. Keeping 
the patient under observation for several weeks will clear up any doubt 
that may remain. 

During the second half of pregnancy confusion with ovarian 
tumors is possible only if none of the fetal signs are available, as, 
for example, in the case of a dead and macerated fetus, and 
in cases of hydramnion. If the latter has caused great distention in 
the uterus, the consistency may be distinctly cystic, and if the junction 
of the vaginal portion with the uterus cannot be demonstrated, the tumor 
is very apt to be mistaken for an ovarian tumor. The best way to guard 
against confounding these two conditions is by examining through the 
vagina or through the rectum and demonstrating a connection between 



SPECIAL DIAGNOSIS 



311 



the vaginal portion and the uterus, or the absence of a normal uterus^ 
The thickness of the wall is also a point in the differential diagnosis, 
inasmuch as even in the most extreme degrees of distention the wall of a 
hydramniotic uterus is still considerably thicker than that of an ovarian 
tumor. An attempt should also be made to trace the course of the 
round ligaments; if they merge with the tumor, the latter is the 
uterus. In the same way, if the sacro-uterine ligaments are lost in the 
tumor, it is certainly the uterus. A distinct uterine bruit is in favor of 
pregnancy. If the objective signs are not sufficient to yield a positive 
interpretation, the history may be utilized. 




Fig. 158. — Kight-sided Parovarian Cyst. P.-F. y^. (Original.) A cystic, very movable tumor 
the size of a child's head. The right tube can be traced far up on the tumor ; within the pedicle the right 
ovary can be plainly palpated. The red line indicates the peritoneal covering. 

Extra-uterine pregnancy is more likely to lead to confusion 
with ovarian tumor than intra-uterine, because the uterus can be dis- 
tinctly isolated from the cystic tumor; or, if the two are closely 
adherent, the tumor at least forms an interruption in the Extra-uterine 
contour of the tumor and can be recognized by its fundus. Pregnancy. 

As a rule, the tumor can be recognized as a gestation-sac by the fetal 
signs, which are distinctly perceptible; in cases of fetal death or intra- 
ligamentary pregnancy this diagnosis is, however, more difficult. In 
most cases the signs of softening will at once suggest pregnancy; soft- 
ening persists for some time after the death of older fetuses. Changes 
in the breasts are rarely wanting. If, in addition, it is borne in mind 
that in the case of advanced extra-uterine pregnancy the history always 



312 GYNECOLOGICAL DL\GNOSIS 

contains certain characteristic data (amenorrhea, signs of pregnancy, dis- 
charge of the decidua), there will be no lack of distinguishing features. 

An absolutely positive distinction between ovarian tumor and 
parovarian cyst is possible only in exceptional cases. Parova- 
rian cysts, which originate in the canaliculi of the epoophoron, are 
Parovarian usually uuilocular, tliin-wallcd, flaccid, with clear, serous 

^^^•^^^ contents. The cysts are always intraligamentary between 

the tube and the ovary; the tube is greatly drawn out and in close con- 
tact with the cyst, while the ovary can occasionally be outlined at the 
base or in the pedicle (Fig. 158). They grow slowly and are seen most 
frequently in young persons. The differential diagnosis is based chiefly 
on feeling the ovary alongside of the cyst; if this fails, the above 
mentioned properties may be utilized. 

For the differential diagnosis from renal tumors, see the latter. 

3. Large Tumors. 

Diagnosis. The large ovarian tumors represent neoplasms which 
distend the entire abdomen; they lie upon the pelvic inlet, extend 
up to or underneath the arch of the ribs, on either side to the 
region of the kidneys, and are in contact with the liver, spleen and 
stomach. They are usually large growths, clinically known as unilocu- 
lar cystaclenomata. In these tumors also the diagnosis depends on the 
demonstration of the pedunculated connection with one horn of the 
uterus; but, owing to the great tension of the abdominal walls and the 
close apposition of the tumor to the uterus, it is usually impossible to 
carry the external hand down far enough to differentiate the tumor and 
feel the pedicle. On the other hand, the diagnosis is practically estab- 
lished if it is possible to demonstrate a circumscribed tumor of cystic 
consistency, as other organs rarely give rise to cysts of the same dimen- 
sions. The tumor itself must of course be demonstrated by palpation, 
which is possible if some parts of the wall are firmer than others. As it 
is often difficult, on account of the tension of the abdominal walls, to 
feel a thin cyst wall, percussion must be resorted to more frequently in 
mapping out the outlines than is the case with medium-sized tumors. In 
general, it may be said that, by percussion, we determine the dulness over 
the tumor and the normal intestinal sound in the two lumbar regions. . 

In the differential diagnosis we must consider first of all the con- 
ditions which are capable of producing similar large tumors, or at 
least of simulating such tumors. The first of these to be considered 
Differential ^re the so-callcd pseudotumors. A thick pannic- 

Diagnosis. ^j^g adiposus, brawuy edema of the abdominal walls, 

severe meteorism, or marked bulging of the abdomen when filled with 
air — a condition which hysterical subjects are capable of producing. 




Fig. 159. — Multilocular Ovarian Cystoma. For this illustration I am indebted to Professor Unter- 
berger of Konigsbeig, who removed the tumor in 1898. The largest circumference of the abdomen was 150 
cm.; the contents, which were removed in three sessions, weighed about 50 Kg.; the cyst itself weighed 2.75 Kg 



SPECIAL DIAGNOSIS 313 

by artificial lordosis — may simulate a large tumor. Percussion is often 
deceptive because it is impossible to bring out the intestinal sound 
through the thick abdominal walls. Considerable force must always 
be used in percussing. If the subcutaneous fat is well 

. . Pseudotumors. 

developed, palpation is particularly likely to deceive the 
examiner when the fat ceases above the umbilical region in a marked 
bulging of the abdomen which makes it appear like the dome of a tumor; 
in most cases of this kind it is impossible to determine the outline of a 
tumor, and an increased tension of the abdomen is all that can be 
made out. In all doubtful cases there is no better diagnostic resource 
than general anesthesia, when the absence of a tumor can easily be 
demonstrated by forcibly depressing the abdominal walls in palpation. 
Free ascites often simulates very large ovarian cysts, and the 
distinction between the two conditions may be fraught with various 
difficulties. A single manipulation of the abdomen may suffice to make 
the diagnosis, or it may be so difficult that all the diagnostic 

FrGG Ascites 

means at our command are inadequate to clear up the 
case. I have seen a very large number of cases in which a positive 
diagnosis was only made at the operation. The diagnostic methods 
employed for distinguishing between these two conditions are as follows : 
Inspection in cases of ascites shows a flat abdomen 
distended in a transverse direction, because in the horizontal position 
the fluid collects in the lumbar regions, which usually bulge, and the 
middle of the abdomen becomes distended only when the 

. . 1111 Inspection. 

accumulation is very great. Tumors, on the other hand, 
particularly the movable ovarian cysts, occupy the middle of the 
abdomen and cause an increase in the sagittal diameter, while 
the lumbar region is only moderately enlarged by the distended 
intestines. Occasionally a shallow constriction may be made out be- 
tween the two prominent portions. The typical shape of the ascitic 
abdomen requires for its production a certain softness and yielding 
quality of the abdominal walls, and is therefore most distinctly seen in 
multiparse, while in the firmer abdominal walls of nulliparous women a 
transverse distention of the abdomen is much less distinctly developed. 
In the presence of an abdominal tumor the conical shape of the abdo- 
men is not affected by a change of position, whereas in ascites the 
protrusion becomes greater in the dependent parts, and the more super- 
ficially situated portions are flattened. Irregular enlargements of the 
abdomen indicate a protrusion due to individual portions of the cyst. 
In free ascites the shape of the abdomen is uniform, and in encapsulated 
ascites the affected part appears more prominent than the rest of the 
body. Sometimes the shape of the costal arch may be of diagnostic 
value, inasmuch as the costal border becomes everted in large tumors 



314 GYNECOLOGICAL DL\GNOSIS 

that have forced their way into the lower aperture of the thoracic cage, 
whereas in ascites the shape of the costal arch is not affected. A typical 
tumor belly is shown in Fig. 159. 

The differences between ovarian tumors and ascites obtained by 
percussion are much more important. Freely movable ascites in 
the recumbent position collects in Douglas' space and in the lumbar 
region, and the boundary between the ascitic dulness and the tympanitic 
intestinal sound is represented by a horizontal line, which in moderate 
degrees of ascites is found in front, above the symphysis, and in the 
sides approximately in the anterior axillary line. The level of this 
boundary line rises in direct proportion with the quantity of ascitic 
fluid; but there is always some tympany at the centre of the abdomen 
because the intestines float in the ascitic fluid and collect at this point. 
When the quantity of ascitic fluid is large, the zone of intestinal tympany 
becomes narrower and narrower, but until the end there remains some 
tympany at the umbilicus and above the umbilicus toward the stomach; 
finally, in extreme degrees of ascites the intestinal tympany disappears 
altogether because the intestines can no longer reach the surface of the 
fluid. The time of the occurrence of this latter phenomenon will depend 
on the length of the mesentery. In chronic peritonitis with, adhesions 
in the mesentery it occurs very early, and the percutory signs in such a 
case may be similar to those produced by a tumor, particularly as the 
intestinal coils in the lumbar regions are prevented by the contraction 
of the peritoneum from getting out of the way of the ascites, and a 
tympanitic intestinal note is therefore obtained in that region. In 
ovarian tumors the relation between dulness and intestinal tympany is 
exactly the reverse. The movable tumor comes in contact with the 
abdominal walls near the middle of the abdomen, producing a dull note 
at that point: while on each side, in the lumbar regions, and above, 
the percussion note is tympanitic. The larger the tumor, the greater 
the extent of the dulness; while the zone of tympany disappears above 
and finally can be demonstrated only in the lumbar regions. In order 
to determine the boundaries between tympany and dulness, which is 
the object of percussion, we begin at the highest point of the abdomen, 
because at that point we are most certain to get a resonant note in 
ascites and a dull note in the case of a tumor; from this point we per- 
cuss downward toward the symphysis, and on each side well into the 
regions of the kidneys, using very little force and marking the boundaries 
as they are obtained. In typical cases the findings are so clear that 
percussion alone suffices to establish the diagnosis. Deviations from 
the normal findings are, however, quite frequent. Thus, for example, 
tympany may be found in the lumbar regions, even in the presence of 
ascites, either because the intestines are very much distended with gas 



SPECIAL DIAGNOSIS 315 

and push the fluid to one side, or because the ascitic fluid cannot make 
its way into the kimbar regions on account of adhesions between the 
intestinal coils and the abdominal wall, as,. for example, in carcinoma- 
tous or tuberculous peritonitis; on the other hand, tympany may be 
absent in the lumbar regions, even in the presence of large tumors, if 
the coils of intestine contain no air. If the diagnosis remains in doubt 
for any one of these reasons, percussion should be repeated after a 
few days and after the administration of a laxative. At the highest 
point of the abdomen abnormal conditions are less frequently encoun- 
tered, except possibly when the intestines lie in front of the tumor or 
gas has developed in the tumor, as in the case of necrotic dermoid 
tumors. The characteristic sign of free ascites is the change in the line 
of tympany or dulness which accompanies a change in the position of 
the patient; since the freely movable fluid always goes to the dependent 
parts and the intestines tend to rise, the percussion note over the upper 
side of the abdomen becomes resonant when the patient is placed in the 
lateral position, while in the lower half the line of dulness extends 
higher up, but the boundary always forms a horizontal line. This sign 
is always present unless the ascites is not freely movable, or the intes- 
tines contain no air. The change in the line of dulness may also be 
determined by examining the patient first in the recumbent, and then 
in the erect position. Tumors usually do not alter their position at all, 
and the percussion boundary remains the same. 

Special difficulties are encountered in the interpretation of the 
percutory signs in the case of myxoid tumors which have rup- 
tured and discharged myxomatous fluid into the abdominal cavity, 
a complication which is quite frequent on account of the thinness 
of the walls of these tumors. In such cases we get the dulness 
of a large tumor situated in the median line and, in addition, dulness 
in one or both lumbar regions, which is due to the fluid accumulated 
in these localities. As, owing to its viscosity, the fluid does not seek 
a lower level with the change of position, the dulness is not movable. 
I have found the explanation for abdominal percutory findings in this 
condition in a great number of cases, and confusion with ascites is all 
the more apt to occur because the tumors are soft and cannot readily 
be palpated. 

A very important sign of ascites is the difference observed 
in the percussion sound when superficial, and when deep percussion 
is made. With tumors of certain dimensions the note obtained 
will always be dull, irrespective of the force used in percussing, 
or whether deep or superficial percussion is employed, because the 
percussion wave cannot pass through the fluid; occasionally a slight 
admixture of intestinal tympany may be encountered at the margin 



316 GYNECOLOGICAL DL\GNOSIS 

of the tumor. In ascites the note will be dull if light superficial percus- 
sion is used; whereas, if the pleximeter finger is pushed well into the 
abdomen, the ascitic fluid is pushed aside and intestinal tj'mpany is 
obtained. In the case of freely movable ascites, this is probably the 
most reliable percutorj' sign, but I have known it to fail when the coils 
of intestine were deep in the abdomen and the mesentery was shrunken. 

In suitable cases palpation may be the simplest method of 
making the differential diagnosis. Cysts with tense walls can sometimes 
be grasped in both hands and their boundaries easily determined, 
particularly in the lumbar regions; whereas freely movable ascites offers 
no resistance 'whatever to the palpating fingers and escapes in all direc- 
tions. Occasionally a certain tenseness of the abdominal walls may be 
produced by the extreme distention of the abdomen which takes place in 
very high degrees of ascites ; fluctuation is quite often a very reliable 
sign. It is elicited bj^ applying one hand to the abdominal wall on one 
side, and gently tapping the opposite wall with the finger-tips of the 
other hand. In ascites a fluctuation wave is produced bj' the slightest 
impact of the fingers and sets up vibrations over the entire abdomen; 
the sign can never be elicited in the case of tumors with tense walls; 
only in thin-walled flabby cysts a wave may occasionally be produced. 
A kind of pscudofiuctuation, due to agitation of the abdomen as a 
whole, sometimes occurs when the abdominal walls are very flabbj\ 
In suitable cases the differential diagnosis between ascites and cyst 
can be made by noting how far the fluctuation-wave extends into the 
region of the kidneys; if one hand is placetl on the abdomen in that 
region, the wave in ascites may often be felt running as far as the ver- 
tebral column, while in tumors it comes to an end much sooner. If 
hard portions are felt in the periphery of an area which is distinctly 
resistant to palpation, they probably correspond to the parts of a tumor; 
whereas in ascites metastases are usually more diffuse, often much more 
movable, and generalh' confined to the region of the omentum. A 
distinct creaking leather sound, which is produced by a displacement 
of the colloid material within the tumor, is also regarded as a sign 
of a colloid tumor. 

The dift'erential diagnosis between ascites and C3'sts with 
ver}^ thin and flabb}" walls, is particularly difficult both in the 
■case of parovarian or ovarian cysts with partly absorbed contents, 
and of C3'sts during the puerperium. In the first place, owing to the 
absence of internal pressure, the tumors in the recumbent position 
collapse and become so fiat that the shape of the abdomen is the same 
as in ascites; or they sink to the deepest portion of the abdomen when 
the position of the patient is changed, so that a change of note is pro- 
duced as in the case of ascites. Another difficidtv is that the wall is 



SPECIAL DIAGNOSIS 317 

hard to palpate, and on tapping with the fingers a distinct fluctuation- 
wave is produced. Mistakes are very oft(!n made in differentiating 
between these two conditions. 

If careful percussion and palpation are employed, and particularly 
if repeated examinations are resorted to, very few cases will be found 
in which the differential diagnosis between ascites and cysts cannot 
be made. In doubtful cases, exploratory puncture may be 
employed. After carefully disinfecting the abdominal walls, the sterilized 
point of an aspirator is introduced at a point on the abdomen where 
dulness has been positively demonstrated. If nothing is obtained 
through a moderately large canula, the condition is probably an ovarian 
tumor with colloidal contents; if fluid is obtained, a positive diagnosis 
may in some cases be made by examining the fluid. A thick, tenacious, 
colloidal consistency, with a brownish-green color and a high specific 
gravity of 1020 to 1040, is in favor of ovarian tumor; whereas in 
ascites the material is pale yellow, greenish, red or brown, from the 
admixture of blood, and the specific gravity between 1010 and 1015. 
As a rule ascitic fluid is very thin, but in the presence of gelatinous 
carcinoma it may have a thick, viscous consistency. Chemical and 
microscopical examinations rarely yield any positive results. The pres- 
ence of pseudomucin, and frequently also of cholesterin, and epithelial, 
usually cylindrical cells, is in favor of ovarian cyst; while in ascites 
leucocytes and a large percentage of albumin should be present. If 
the contents of the tumor escape into the abdominal cavity, these signs 
are obscured. Exploratory puncture is now rarely employed by expert 
diagnosticians. 

For the differential diagnosis between encapsulated ascites 
and ovarian tumors see page 307. 

When ovarian tumors are complicated by the presence of 
ascites the diagnostic difficulties are increased, because percussion 
yields a combination of the percutory signs characteristic "of both con- 
ditions; the intestinal tympany persists longest in a zone 
under the costal arch on both sides. The most reliable Ascites with 
results are usually obtained by changing the patient's ''^"^° umors. 
position, because the sound becomes resonant in the upper flank. If 
the tumor is larger than the ascitic collection, it is often impossible to 
demonstrate the presence of the latter; if fluid collects between the 
individual portions of the tumor and the abdominal wall, circumscribed 
areas with very distinct fluctuation are obtained. Extraordinary 
mobility — so-called dancing of the tumor — points to complication 
with ascites; on the other hand, if the mass of the ascitic fluid is greater 
than that of the tumors, the latter are much less conspicuous. Even 
under anesthesia it is often difficult to demonstrate a tumor and to 



318 



GYNECOLOGICAL DIAGNOSIS 



make out its outlines, consistency, and the pedicle connecting it with 
the uterus. The very important diagnosis of small papillomata or 
fibrosarcomata of the ovary is exceedingly difficult in the presence of a 
marked degree of ascites. If there is reason to suspect that such tumors 
are the cause of the ascites, the fluid should be drawn off through a 
puncture, when the tumors will be recognized with great ease in the 
completely emptied abdomen with its flabby abdominal walls. I do 



Liver 



" — - — Stomach 




Col. trans- 
versum 



Fig. 160.— Pancreatic Cyst (after Sitzenfrey). The cyst lies between the colon and the stomach in con- 
tact with the abdominal wall, having caused extreme distention of the gastrocolic ligament. 

not consider exploratory laparotomy permissible in cases of this kind 
unless there is reason to expect that there will be tumors to remove, 
because the danger of infection is greater in carcinomatous patients 
than under ordinary circumstances, and the patients are already so 
weak that they do not get on their feet again after the laparotomy. 

In pancreatic cysts the seat of the tumor is the most char- 
acteristic feature. It develops under the left costal arch and grows 
from above downward; as the tumor increases in size the stomach and 
liver are displaced upward, while the gastrocolic hgament becomes 



SPECIAL DIAGNOSIS 



319 



Pancreatic 

Cysts. 



gr;;^ 



greatly stretched and the transverse colon is crowded downward. Only 
very large cysts extend as far as the genitalia. The consistency of the 
tumor is usually everywhere distinctly cystic. Pancreatic cyst may 
be mistaken for an ovarian tumor situated high up in 
the abdomen, or, on account of the diminished mobihty, 
for an adherent ovarian tumor. The patient's statement that the cyst 
grew from above downward is against ovarian tumor, as is also the 
circumstance that the greatest prominence is always found at the 
umbilicus, in the neighborhood of the pancreas. The surest way to 
exclude ovarian tumor is by determining the boundary of the genital 
organs by bimanual examination. Ex- 
ploratory puncture, which is recom- 
mended by some authors, and which is 
said to yield pancreatic ferments that 
can be definitely identified by chemical 
analysis, is not always reliable and may 
be dangerous on account of possible 
injury to the stomach, which is situated 
above the -cyst. 

Retroperitoneal and mesen- 
teric tumors are often mistaken 
for ovarian tumors if they cause great 
distention of the abdomen and extend 
as far down as the pelvic inlet. Under 
these circumstances also the ovarian 
tumor could always be excluded with- 
out any difficulty if both ovaries were 
palpable and any connection between 
the tumor and the uterus could be 
excluded; but that is not always pos- 
sible. The consistency is of no value 
either, because pure cysts may have their origin in retroperitoneal and 
mesenteric organs, and because retroperitoneal myxoma and sarcoma, 
owing to their softness, may simulate cysts. 

The relations between the tumor and the intestine are characteristic 
in many cases. Whereas freely movable ovarian tumors push the intes- 
tines aside and are surrounded by tympany, retroperitoneal and mesenteric 
tumors often push the intestinal coils in front of them against the abdom- 
inal wall, and the note at the highest point of the tumor is tympanitic. 

Splenic tumors may also be mistaken for ovarian cysts if 
they grow into the pelvic inlet, and particularly if they are the seat 
of cystic degeneration (echinococcus). If the latter is not the case, 
the peculiar parenchymatous consistency alone is indicative of a splenic 




Fig. 



161. — Pancreatic Cyst. 
Flaischlen.) 



(After 



320 



GYNECOLOGICAL DIAGNOSIS 



Splenic Tumors. 



tumor, and it may further be recognized by its oblique position and 
the fact that it disappears under the costal arch. If a floating spleen 
is produced, the position of the tumor may, of course, be materially 
altered. For example, I once saw a large splenic tumor 
placed transversely across the pelvic inlet, leaving the splenic 
region proper entirely free. As a rule, notches are felt on the inner and 
upper margin of the splenic tumors extending several centimeters into 
the mass (Fig. 162). Echinococcus cysts of the spleen are large cystic 

tumors without the above 
splenic characteristics, 
but as a rule they also 
disappear under the left 
costal arch. It is almost 
needless to say that in 
this condition also an 
attempt should be made 
to find the ovaries by 
bimanual palpation and 
to exclude any connection 
between the tumor and 
the uterus. All splenic 
tumors are characterized 
by their position under 
the left costal arch, or at 
least by the fact that 
they can be replaced 
into that region. 
, I Tumorsofthe 

\ f liver are occasionally 

taken for ovarian tumors 

Fig. 162.-LARGE Sple^c Tumor^^J^owing Distinct Notches. ^f ^J^gy extend tO the pel- 

vic inlet; or they may be 
mistaken for ovarian tumors that have become fixed in the region of the 
liver by the formation of adhesions during pregnancy or the puerperium. 
Uniform enlargement of the liver is most easily recognized by the pecu- 
Tumorsof ^ar parenchyHiatous consistency, by the well defined lower 

the Liver. hepatic bordcr, and the characteristic direction of the 

tumor obliquely upward against the xiphoid process, as well as by the notch 
for the gall-bladder. In addition, all tumors of the liver are more or less 
distinctly movable with respiration. The mistake of diagnosing an ovarian 
tumor is most apt to be made in the case of enlargement of one lobe, sepa- 
rated from the liver by a constriction (Schniirleber) ; large hepatic tumors; 
and especially echinococcus cysts. Every effort should be made to 




SPECIAL DIAGNOSIS 



321 



establish a connection between the tumor and the genitaha or the 
liver. Often the character of the mobility is in itself distinctive, since 
pedunculated tumors of the hver are readily pushed upward and resist 
any attempt at downward displacement, whereas ovarian tumors 
move upward with difficulty but can easily be displaced downward. A 
positive diagnosis can be made only by finding a broad or cord-hke 
connection with the liver or a pedunculated attachment to the uterus. 
Ovarian tumors of medium and excessive size may, of course, also 
be confounded with subserous myoma t a, although the points 
of difference which have been explained in connection with the differ- 
ential diagnosis of smaller tumors (see 
page 301) apply to this variety also. 
It should nevertheless be mentioned 
that cystic degeneration is more frequent 
in large myomata, and certain portions 
of the tumor may, therefore, greatly 
resemble an ovarian tumor; that, more- 
over, even in the case of multilocular 
cysts the consistency may be quite as 
firm as that of myoma. Nevertheless, 
the difference in consistency, as well as 
the connection with the uterus by means 
of a pedicle, is an important diagnostic 
point. The diagnosis of a large myoma 
may be rendered very much easier if 
the uterine cavity is elongated, although 
it must be remembered that in the 
presence of myomata the sound very 
frequently fails to reach the fundus, and the measurement obtained 
may therefore be deceptive. Large fibromata in the pelvic connective 
tissue are particularly apt to be mistaken for ovarian tumors, partic- 
ularly if they have a thin pedicle and the consistency is 
soft. Interstitial soft myomata may also give rise to 
error if the junction between the cervix and the uterine body cannot 
be positively recognized and it is therefore impossible to demonstrate 
that the tumor is of uterine origin. If the junction of the folds of 
Douglas with the tumor can be definitely felt through the rectum, 
it is a decisive sign in favor of myoma (Sellheim). 




FiG. 163. — Tumor op the Right Lobe of 
THE Liver. P.-F. ]/i. (Original.) Above 
the tumor is the gall-bladder ; the genitalia 
can be distinctly outlined. 



Diagnosis of Certain Complications. 

The clinical picture of a simple ovarian tumor is very much changed 
when comphcations develop. Such an occurrence is significant in va- 
rious respects. In the first place, an originally benign cyst may undergo 



21 



322 



GYNECOLOGICAL DIAGNOSIS 



malignant degeneration and destroy the patient's life; or the prognosis 
of an operation may be greatly influenced by the intraligamentary 
development of the tumor, or the presence of extensive adhesions, 
twisting of the pedicle, rupture of a large cyst; or suppuration of a 
tumor may convert a simple cyst into the cause of a serious and often fatal 
disease. Hence the physician must learn to recognize these complications, 
and he is in need of guidance for this puspose, as the above described 
diagnostic signs require emendation in several important respects. 

Diagnosis of Intraligamentary Seat of the Tumor. The pecu- 
liar characteristics of this form are more pronounced when the tumor 

is entirely situated between the two 
layers of the broad ligament and grows 
toward the uterus. If, on the other 
hand, it is situated in the lateral por- 
tion of the broad ligament it may have 
the characteristics of a pedunculated 
tumor, the pedicle being formed by the 
free portion of the broad ligament, 
which becomes greatly distended. Paro- 
varian cysts, in spite of the fact that 
they are often entirely intra-ligamen- 
tary, frequently possess a long-drawn- 
out pedicle of this kind, which per- 
mits a considerable degree of mobil- 
ity and may even become twisted. 
Intraligamentary ovarian tumors all 
exhibit a certain degree of immobility 
because they are fixed to the pelvic 
floor by the investing layer of the broad 
ligament. Sometimes the immobility 
is only slight because the peritoneum is yielding. The degree of mobility 
is determined by attempting to move the tumor from above downward 
in bimanual palpation; the tumor will be found to be movable up to 
a certain limit, which is determined by the attachment of 
the infundibulo-pelvic ligament to the pelvic wall, but it 
can never be entirely pushed back out of the (false) pelvis. 
It is true that incarcerated and adherent tumors are also 
Incarceration is, of course, to be assumed only if the 
size of the tumor is greater than the width of the pelvis. In the 
case of adherent tumors the fixation is usually much more complete 
and can be directly felt to be due to adherent bands or exudates at the 
base of the tumor, while intraligamentary tumors are surrounded by 
soft, readily movable tissue. When the base of the tumor only is within 




Fig. 164. — Bilateral Intraligamentary 
Papillary Ovarian Tumor. P.-F. J^. 
(Original.) The tumor on the right side is situ- 
ated deep within the true parametrium, that on 
the left, above, in the broad ligament. Both 
are so united with the uterus that the fundus 
cannot be outlined ; only the cervix and a 
piece of the body are palpable. Sound, 7 cm. 
Both tumors exhibit papillary excrescences 
('trees'). 



Diagnosis of 
Intraligamen 
tary seat of 
the Tumor. 



immovable. 



SPECIAL DIAGNOSIS 323 

the broad ligament it often forms a fixed point around which the dome 
of the tumor can be moved. The relation of the tumor to the uterus is 
very important for determining whether it is intraligamentary; but 
great diflferences of course exist in this respect also, depending on the 
proximity of the tumor to the uterus. In many cases it lies so close to 
the organ that the two are only separated by a shallow constriction, 
or the fundus only can barely be differentiated. The uterus may be 
attenuated and drawn out lengthwise by the close apposition of the 
tumor, to such an extent that its presence can only be demonstrated 
with a sound; or the tumor may encroach on the uterine muscle so that 
it seems to originate in the uterine wall. In other cases again, when the 
broad ligament is not entirely unfolded, and there is a considerable inter- 
val between the uterus and the tumor, it is not possible to demonstrate 
the connection between the two, and both masses can easily be moved 
one against the other. The characteristic sign in all cases of this kind 
is that the tumor is actually connected with the lateral aspect of the 
uterus. Even this sign is less distinct if the median portion of the 
broad ligament is free, as in that case the uterus may be displaced so 
far forward or backward that the tumor appears to be either in front 
of or behind the organ; but by bringing the two together the connec- 
tion between them can be plainly demonstrated. The anterior surface 
of the uterus usually forms a continuous contour with the anterior 
surface of the tumor covered with broad ligament, while the posterior 
layer is greatly displaced upward by the growth of the tumor. The 
latter then takes up its position at the posterior surface of the uterus, 
where it is not covered with peritoneum, and gives the impression of a 
retro-uterine tumor. Separation with upward displacement of the 
anterior layer is much more rare, although it is occasionally observed, 
particularly in the case of papillary tumors which grow around the 
bladder into the preperitoneal excavation of Retzius. Occasionally an 
intraligamentary tumor grows far down into the pelvis if it penetrates 
into the base of the pelvis — the true parametrium. Such tumors are 
deeply placed on the floor of the pelvis and have a situation similar to 
that of pedunculated tumors lying deep down in Douglas' space. If 
they are situated more in the true broad ligament they project far above 
the pelvic inlet. Displacement of the uterus, especially if the dis- 
placement is exactly to one side, is a conspicuous sign of intraligamen- 
tary tumor. Retro-uterine or laterally situated pedunculated tumors 
which are prevented from growing upward by incarceration or by adhe- 
sions also displace the uterus in order to gain room for their growth, 
but the displacement is usually only to one side and forward. Bilateral 
intraligamentary tumors often force the uterus completely out of the 
pelvis; occasionally one tumor is found high up, and the other low 



324 GYNECOLOGICAL DIAGNOSIS 

down alongside of the uterus. Palpation of the adnexa may also assist 
in determining the seat of an intraligamentary tumor if the long-drawn- 
out tube is found in close apposition with the tumor and the round 
ligament passes obliquely over the anterior surface to the internal 
ring. A sign which is absolutely reliable in the differential diagnosis 
between an intraligamentary tumor and one situated deep down in 
Douglas' space is the direction of the folds of Douglas; but, unfortu- 
nately, they cannot always be felt. If the fold is felt in front of 
the tun^or, the latter occupies Douglas' space (Fig. 165) ; whereas in 
the case of intraligamentary tumors the fold is pushed backward and 
toward the median line (Fig. 166). Large intraperitoneal cysts cause 
stretching of the corresponding fold of Douglas so that the intermediate 
portion escapes palpation, while the two extremities are distinctly felt 



^^^^ 




Figs. 165 and 166. — Behavior of the Folds of Douglas with Retko-uterine and with Intraligamen- 
tary Ovarian Tumors. Vi. (Diagrammatic.) (Original.) 

and the fold as a whole can be pulled away from the tumor. In 
the case of intraligamentary tumors growing in close apposition with 
Douglas' fold, the latter is often completely flattened so that it can 
not be picked up (Sellheim). 

The diagnosis of adhesions presents few difficulties if the tumor 
occupies the pelvis. Their presence is at once indicated by the fact that 
the tumor cannot be replaced, unless this is due to incarceration or to 
an intraligamentary position of the growth; as a rule, the short bands 
of adhesions, which are very sensitive to pressure, are 
AciiSi*ons.°^ felt at the base. If the tumor occupies the false pelvis, it 
must be determined whether parietal adhesions are present. 
These are most easily recognized by immobility of the tumor. Whereas 
a tumor, unless it be very large, can easily be moved from right to left 
and, if the position of the pedicle does not interfere, from above down- 
ward, the mobility is entirely abolished in the presence of diffuse parietal 



SPECIAL DIAGNOSIS 325 

adhesions and the tumor Ues in close contact with the abdominal walls. 
It is true that great tension of the abdominal walls may occasionally 
interfere with the mobility of a large tumor to such a degree that it 
appears to be adherent. Partial adhesion to the anterior abdominal 
walls is often recognized by forcibly displacing the tumor, as this is 
accompanied by retraction of the abdominal wall at the corresponding 
point. Local pain on pressure or a peritonitic friction-sound suggests 
adhesions from recent peritonitis. Intestinal adhesions may be sus- 
pected if the tumor is broadly adherent to the anterior abdominal 
wall; their presence is assured only if a soft, ribbon-like resistance is 
commonly felt in certain definite regions, and gurgling noises are 
elicited in the supposed situation of the adhesions. Adhesions with 
the omentum, the liver, and the spleen cannot as a rule be recognized 
with certainty. 

The diagnosis of torsion can be made by directly palpating the 
twisted pedicle only in exceptional cases. Sometimes the pedicle 
appears to be unusually thick and short, or constriction can be felt on the 
surface, or, as in especially favorable cases, it may be 

' ' . ^ -^ . . Diagnosis of 

possible to feel individual twists. As a rule, twisting of Torsion of 

. -Ill- • the Pedicle. 

the pedicle is recognized only by its consequences; m 
very rare cases there is complete absence of all symptoms, and the 
operator is surprised to find a twisted pedicle. In some cases the only 
symptom is pain, which rapidly increases and subsides again, particu- 
larly at the menstrual period; but the most important sign of torsion 
is found in sudden attacks of acute pain often following a slight trauma- 
tism (raising the patient, turning over in bed), and associated with 
nausea and vomiting. The pain disappears in a short time, to recur 
repeatedly if new adhesions are formed after the attack. Usually, 
but not always, general peritonitis develops with moderate fever, rapid 
pulse, and meteorism; during the acute stage the tumor cannot be 
distinctly felt on account of the great meteorism. When the abdomen 
collapses, the outlines of the tumor gradually stand out and become 
more and more distinct as the inflammation subsides. If a peritonitis 
develops before the presence of a tumor has been suspected, the diag- 
nosis may remain in doubt for a long time; on the other hand, if diffuse 
inflammation develops in a case in which ovarian tumor has been posi- 
tively demonstrated, the most frequent cause is torsion of the pedicle. 
The condition may be suspected in the presence of general adhesions 
with the intestines, the abdominal walls and the uterus, which have 
resulted from a diffuse peritonitis. Torsion is most frequent in the 
case of medium-sized tumors. 

Rupture of an ovarian tumor is a not infrequent accident, par- 
ticularly in the case of thin-walled, myxomatous cystadenomata. The 



326 GYNECOLOGICAL DIAGNOSIS 

signs of rupture are produced by the escape of fluid into the abdominal 

cavity and vary according as the fluid escapes slowly or rapidly in large 

masses, and according as the contents are serous, colloidal, myxomatous, 

or purulent. The escape of small quantities of serous or 

Rupture of ^ . ^ ^ . . 

an Ovarian myxomatous material hardly makes any impression; the 

escape of larger masses is usually the cause of sudden and 
violent pain, often accompanied by vomiting and followed by symp- 
toms of peritonitis, moderate in degree, as in the case of torsion, 
and without the character of septic phenomena. Sudden death 
sometimes follows rupture of an ovarian tumor before a peritonitis 
can develop. The escape of purulent contents may lead to a rapidly 
fatal septic peritonitis. Large myxomatous masses remain in the 
abdominal cavity because they cannot be absorbed and form a thick 
envelope around all the abdominal organs. As a rule, the condition 
is not attended by any clinical symptoms or inflammatory reaction. 
The development of peritoneal symptoms is accompanied by objective 
changes in the tumor, which either disappears altogether or is much 
reduced in size and collapsed. 

Suppuration of an ovarian tumor, most frequently from infection 

with streptococci, typhus bacilli or bacterium coli, may be suspected 

if the patient has been exposed to an infection (puerperium, typhoid 

fever), and a protracted febrile condition develops, with 

Suppuration 

of an Ovarian increasing loss of strength for which no other cause can be 

Tumor. . . .»,., 

round, ihe tumor is not necessarily painiul, either spon- 
taneously or on pressure, so long as the serous coat is not infected. 
If symptoms of peritoneal reaction develop, the mystery is solved, 
and the long-sought-for cause of the fever is found. The fever is 
accompanied by a high degree of leucoc5^tosis. 

Pregnancy, which as a rule occurs only with small or medium-sized 
tumors, endangers the woman's life in a variety of waj^s through mechan- 
ical interference with parturition, rupture and torsion of the pedicle, 

and suppuration during the puerperium. It is, there- 

Pregnaney. « . . , » 

tore, important to recognize the occurrence of pregnancy, 
because it usually requires immediate removal of the tumor. During 
the early months the diagnosis may be difficult if the tumor interferes 
with palpation of the uterus; if the tumor and the uterus are of approx- 
imately the same size and occupy the abdomen, the suspicion of bilateral 
tumor may be at first entertained, until the characteristic properties of 
one of the tumors and its junction with the vaginal portion identify it 
as a gravid uterus. The recognition of a tumor alongside of a large 
gravid uterus during the later months may be difficult if the tumor 
which usually rises with the uterus, sinks into the lumbar region where 
it cannot be palpated; or, on the other hand, if the tumor lies close to 



SPECIAL DIAGNOSIS 327 

the uterus. Under these circumstances the points to be especially 
noted are: the distinctly cystic consistency of the ovarian tumor and 
the thickness of the wall. An attempt must be made also to demon- 
strate a division between the two masses, even if it is no more than a 
distinct furrow; if the uterus and the cyst become so large that there is 
not room for both in the abdominal cavity, delimitation may be very 
difficult, as shown by the following case. 

Case 27. Mrs. H. presents herself on the 19th of January, 1894, on account of a 
great increase in the size of the abdomen; circumference at the navel, 122 cm. A large tumor 
fills the entire abdomen, dull on percussion; intestinal tympany is elicited in both lumbar 
regions; massive fluctuation over the entire tumor. The vaginal portion appears somewhat 
soft, and its junction with the tumor is to the right of the median line; in the right anterior 
vaginal vault a fetal head is indistinctly felt; to the right above, under the arch of the ribs, 
another large fetal part. I was, therefore, compelled to assume a pregnancy, although the 
distinct fluctuation, the thin walls of the tumor, and the distinct palpation of fetal parts on 
the right side did not tally with the diagnosis of hydramnion. As the combination of ovarian 
tumor and pregnancy did not seem to me probable because it was impossible to demonstrate 
any furrow or division between the pregnant uterus and the tumor, I considered a twin preg- 
nancy with a single hydramnion as the most hkely explanation, in spite of the fact that the 
uterine wall on the left side appeared to be too thin. The last menstruation had occurred 
at the end of May, 1893; on the first of March, the woman was delivered spontaneously and, 
after the birth of the child, a large, flabby, thin-walled tumor remained behind. The uterus 
had been embedded in the right wall of the tumor, in which it had formed a deep depression, 
so that the two represented a single tumor. At the operation, which was performed later, a 
parovarian tumor was found. 

Small tumors occupying the true pelvis are not easily recognized as 
ovarian tumors because the tension of the tumor wall is so great that 
they are mistaken for myomata, particularly as, owing to their close 
apposition to the uterus, it is difficult to make out a separation, or to 
palpate the pedicle; quite often a positive diagnosis can be made only 
under chloroform anesthesia. Diagnostic errors, which are not rare, 
usually consist in overlooking pregnancy during the early months, and 
the tumor during the later months of gestation. 

The diagnosis of malignancy is of vital importance because it neces- 
sitates immediate removal of the tumor. In certain respects the tumors 
themselves may arouse a suspicion of malignancy by certain easily 
Diagnosis of rccognizcd peculiarities, for which the reader is referred 
Malignancy. .j.^ |.]^g description of the palpatory peculiarities of carci- 
noma, sarcoma, endothelioma and teratoma in another part of the 
book. In addition, we have a number of other peculiarities and devia- 
tions from the clinical pictures of a simple tumor which, when taken 
together with the palpatory findings, usually make a positive diagnosis 
of malignancy possible. For instance, malignancy may be suspected 
in the case of bilateral tumors of approximately ec^ual size, and when a 
tumor develops partially within the broad ligament. Ascites is regu- 
larly found with malignant tumors and is therefore always suspicious; 
but it is not a positive sign of malignancy. Moderate quantities of 



328 GYNECOLOGICAL DIAGNOSIS 

ascitic fluid are found with glandular cysts, and ascites in large quanti- 
ties may be present with fibromata and fibrosarcomata, and particu- 
larly with papillomata as soon as the papillae reach the surface. The age 
is of little value in the diagnosis of malignancy. Malignant tumors 
may occur in young individuals and, on the other hand, advanced age 
is not incompatible with the presence of benign tumors. Marasmus 
and cachexia are also possible accompaniments of large benign tumors; 
but if the tumor is small, they are suspicious factors. Edema of the 
legs developing early in the presence of a small tumor I regard as one 
of the niost positive signs of malignancy. It follows, therefore, that 
the diagnosis is not absolutely certain so long as the carcinoma is con- 
fined to the tumor; it becomes positive only when the malignant pro- 
cess has spread to the surrounding structures, as malignant tumors 
form a broad and massive attachment to their surroundings and become 
absolutely and immovably fixed. By dissemination of the carcinoma 
metastases are foriued on the floor of Douglas' space and on the pelvic 
peritoneum, appearing either as solitary nodules or as coherent brawny 
masses. In combined examination through the rectum and vagina 
these nodules can usually be separated from the main tumor, and by 
moving the hands up and down a rubbing, crunching sound — so-called 
'snowball crunching' — is produced. Similar sensations are felt in the 
presence of hemorrhages in Douglas' space, tuberculous nodules on 
the peritoneum, and papillary excrescences on the surface of ovarian 
tumors, and the distinction from carcinomatous metastases is made by 
the fact that in the latter case the crunching sound is much coarser 
and more intense. From the hilus of the ovary carcinomatous masses 
make their way into the pedicle, and hence into the broad ligament 
and parametrium, where they produce solitary nodules, or more fre- 
quently a coherent, cartilaginous thickening. In this way the base of 
the tumor becomes surrounded by irregular nodular masses. If nodular 
tumors are found in the upper portions of the abdomen, especially in the 
region of the omentum and transverse colon, they are to be regarded as 
metastases and indicate malignancy; they must not, however, be mistaken 
for scybalous masses or a crumpled, contracted omentum, such as we find 
in tuberculous peritonitis. In many cases the true nature of the tumor will 
be revealed only by inspection at the operation. As ovarian carcinoma is 
usually metastatic, a search should be made for a primary carcinoma in 
the abdomen, which is usually found in the stomach or in the intestine. 

Diagnosis of the Variety of the Ovarian Tumor. 

After the diagnosis of ovarian tumor has been definitely estab- 
lished, the physician, whether he be a general practitioner or a specialist, 
should try to determine to what variety the neoplasm belongs, as both 



SPECIAL DIAGNOSIS 329 

prognosis and treatment depend on the decision of this question. In the 
main it may be said that this is not difficult in the majority of tumors. In 
a few cases, however, even the specialist will be unable to make the diag- 
nosis clinically, and the classification of the tumor must be left to the 
pathologist. The following points are available in making the diagnosis. 

1. Follicular cysts, as a rule, are of about the Follicular 
size of a fist; they are usually unilocular, have thin, ^^^*^' 
moderately tense walls, and the contents are pale and serous; the 
cysts are usually unilateral, show little tendency to form adhesions 
and, if favorably situated, rarely produce symptoms (Fig. 167). 

A subvariety of follicular cyst is found in certain cystic tumors of 
the ovaries which develop on an inflammatory foundation. These 
'inflammatory cysts' result from retention in one or 
several follicles, occurring with inflammatory pro- 
cesses in the adnexa, and are therefore found asso- 
ciated with tubal diseases, adherent peritoneal cysts, 
and parametritic conditions of various kinds. They 
are usually bilateral and adherent to adjoining struc- 
tures, and the contents are serous. If a communi- 
cation is established between an inflammatory cyst 
and a coincident hydrosalpinx, there results a tubo- 
ovarian cyst, a combination of a moderately large ova- 
rian cyst with a dilated tube, the abdominal extremity •^'°- le/.— follicu- 

•' ' •' LAR Cyst of the Ovary. 

of which usually forms the connection with the ovary. (Specimen from the 

■' . "^ Kgl. Universitats - Frau- 

These inflammatory cysts can be recognized enkiinik in Konigsberg.) 
clinically by the symptoms of inflammation, the right of the cyst, some 

1, c ,-t , 1,1 n- remains of ovarian tissue. 

irregular shape of the tumor, and the many adhesions 
with surrounding structures. Tubo-ovarian cysts, which rarely exceed 
the head of a child in size, can sometimes be recognized by their peculiar 
shape — like that of a retort — which is produced by the reflection of the 
dilated tube in the spheroidal ovarian portion of the tumor (Fig. 168). 

2. Corpus luteum cysts, which are usually not larger than 
the fist, have thick walls but otherwise are not characterized by any 
special peculiarities (Fig. 169). 

3. Simple serous cysts (cystoma serosum simplex) are uni- 
locular, thin-walled tumors, or, rarely, made up of two or three cavities 
placed side by side. The contents are fluid; clinically they differ very 
little from follicular cysts except that they attain a much larger size. 

4. Proliferating glandular cyst (cystadenoma pseudo- 
mucinosum) is the commonest clinical variety of ovarian tumor, and 
may be of any size. In the simplest cases it is approximately spherical, 
and this shape is retained when a large cyst predominates in the tumor; 
the shape becomes irregular by the development of several cysts on the 




330 



GYNECOLOGICAL DIAGNOSIS 



outer surface of the main tumor, in which case numerous constrictions 

and divisions are found. When the tumor consists chiefly of one large 

cyst, the surface is smooth; but when several cysts project from the 

tumor it becomes nodular. The consistency of the tumor 

Cystoma 

Gianduiare clepeuds ou the size of the cysts; small tumors usually 

have a solid feel; large tumors are distinctly cystic and 
present separate areas of fluctuation when there are several larger 
cysts, or continuous fluctuation when the tumor consists of a single 
large cavity. Multilocular cysts with small cavities are sometimes 
absolutely hard and without fluctuation anywhere. In most large, 




Fig. 168. — Tubo-ovariax Cyst (after Martin). 



distinctly cystic tumors hard areas are found in the wall which corre- 
spond to parts that have not yet undergone cystic degeneration. The 
mobility in the case of pedunculated ovarian tumors is quite great, 
unless it is interfered with by tension of the abdominal walls or by 
adhesions. Large tumors usually form adhesions, most frequently 
with the omentum, intestines, or abdominal wall; rarely with the uterus 
and pelvic organs. Cystadenomata are often unilateral and usually 
pedunculated; ascites is rare and when it is present, the quantity of 
fluid is small (Fig. 170). 

5. Proliferating papillary cystoma (cystadenoma sero- 
sum, papillary cystoma — Pfannenstiel) rarely exceeds the size of a 
man's head. Most of the tumors are about as large as a child's head; 
the shape is rarely absolutely round, the surface is nodular or bosse- 
lated, and often covered with distinctly palpable papillary excrescences. 



SPECIAL DIAGNOSIS 



331 



Cystoma 

Papillare 

Proliferans. 



Quite often the consistency is not recognized as cystic because the 
cavities are small and filled with papillary masses. In the great majority 
of cases these tumors are bilateral, or at least one of the tumors is 
generally intraligamentary ; but they are rarely entirely 
within the broad ligament. As a rule the base only is 
intraligamentary, while the periphery is free. Adhesions 
with adjacent organs and with the pelvic peritoneum are very fre- 
quent: hence absolute mobility is rare. Peritoneal metastases are 
very often found in advanced cases, particularly in Douglas' space. 
Ascites occurs early, especially when the surface is covered with 
papilhie; the quantity of fluid is usually abundant. Superficial 
papilloma represents 
a distinct papillary tree 
on a normal ovary; it 
is usually bilateral and 
early causes ascites 
(Fig. 171). 

6. Primary car- 
cinoma t a in the main 
have the same shape as 
the ovary ; if they increase 
in size, the surface be- 
comes irregular from pro- 
truding nodes and cysts. 
Small tumors are hard; 
larger tumors are cystic 
in places because soften- 
ing processes not infre- 
quently take place in the 
interior of the tumor (Fig. 172). The pedicle is usually short, and 
often inserts in a hilus of the tumor. (For other clinical peculiarities 
see page 327). If a carcinoma develops secondarily in a cystadenoma, 
the characteristics of the latter remain unchanged so long as the 
carcinoma is confined to the interior of the tumor. 

7. Dermoid tumors rarely exceed in size a man's head; most 
frequently they range between the size of a hen's egg and that of a 
child's head; they are approximately round or oval, and frequently 
have the shape of a biscuit with a suggestion of a division. 
The contents consist of fluid, fat, hair and teeth, growing 
out of the epidermoid inner wall; the wall of the tumor not rarely 
contains pieces of bone, which can be plainly felt if the tumor is in a 
favorable situation. Dermoid cysts of moderate size often give the 
impression of a hard, solid tumor because the wall is usually thick and 




Fig. 1G9. — Corpus Luteum Cyst (after Martin). 



Dermoid. 



33^2 



GYNEr()i.()(;i(Ai. 1)ia(;n()S1S 



tense; (he cysts ni-c ol'lcn clinraclrrizcd l>y '^vciit scnsiiivrnoss on 
])r(\ssur(S iuiLl occasionally ^i\-c rise l,o spontaneous |)aiii. Thry fi;i'o\v 




Fio. ITO. — Oystadenoma PsBunoMUCiNOSdM. '■;. (Orii^liml,') (I'li'painlioii from llio Km:!. I'lii- 
vorsitiltM-rnuioiiUliiiiU in Kiiiiigsborg.) In Mdmc o( tlu' (\vsls llic ccmiIi'iiIn nro ouumihilril ; uIIutm urn I'lnply ; 
small piipillio dtntilop in a fow of tho oj'sts. 

very slowly and twc most frcinnMitly ohscrx'rd in youiiti; persons. 
They are rarcdy hilaleral. hernidid (iiniors ol'len become adiu'rent 




Fio. 171. — (1ystadknom.\ Sebosum (after Cloblmnn. (Spooiinon frum thf Kj;!. Uiiivprsifiils-l'^'auouklinik 

ill Ht'riin.) 

to adjacent organs and are expos(>d (o infection I'lom (he intestine; 
as a resnlt gas is generat(Ml within I lie tumor and peiforation into 
neighboring organs takes placi' i,Fig. 173). 



si'KCiAL i>i \^,\o.-;i,- 



tifiH 



Teratoma, 



8. Tcratomata are composed of various embryonal organs 
(|f;rivod from the three germinal layers. They represent tumors cxceed- 
i/ig in size a man's head, are often observed in youthful individuals, 
and grow rapidly. The consistency is firm, often hard; 
the bone, which is a frequent constituent of the tumor, 
may be exceedingly hard; the surface is smooth and sometimes nodu- 
lar; tlie tumors are usually connected with the uterus by a pedicle. 
If the tumor is malignant, which is not always the case, ascites and 
metastases develop. A clinical diagnosis is rarely possible; if abundant 
masses of bone are present it may be possible with the aid of radiography. 

9. Ovarian fibromata are approxi- 
mately round or oval, very hard, with a smooth, 
slightly lobulated surface, and generally uni- 
lateral. They may be larger than a man's head, 
early lead to ascites, and fre'jueni.ly contain 
cysts in their interior (Fig. 174;. 

JO. .Sarcoma occurs in two distinct clin- 
ical and pathological forms: 

Fibrosarcoma ^spindle-cell sarcoma) 
may be twice as large as a man's head, lobulated 
and hard. The tumors are usually bilateral 
and produce ascites, benign, do not harl to 
metastasis, and do not recur (Fig, 17oy. 

Hound-cell sarcomata are soft, medul- 
lary tumors with a fairly smooth surface; they 
are usually unilateral, and often give rise to 
ascites. They sometimes attain a consider- 
able size. The neoplasm early breaks through 
the surface and causes infection of adjacent 
structures, especially the abdominal cavity. 

II. Perithelioma and endothelioma 
properties as round-cell sarcoma. 

In connection with the foregoing, I shall discuss at this point: 




!'",'«"-•/' O/ABIASf 

from t}(e 
-iiklinik in 

ijitH0: ffOtt'mWi of 
the carir;inir»nria.(t/iij« ti««(je iiave 



have the same 



The Diag^nosis of Acute and Chronic Oophoritis. 

A pohji.iv*; diagnosis oi acui e oopnoriiih can be made only 
when the ovary can be isolated by palpation. The mo.st important 
alteration consists in swelling of the organ, which rarely exceeds in 
size that of a hen's egg or a goose egg (see Case 23). a^^*^ 

Depending on the degree of alteration, the consistency of the Oopiw«t«, 
ovary becomes soft and compressible, or even fluctuating if an abscess 
is present; a certain degj- rnsitiveness Is rarely absent. The 

constitutional symptoms, spoxxianeous pain and onset with fever, 



334 



GYNECOLOGICAL DIAGNOSIS 



which constitute the symptoms of acute oophoritis, are of value in the 
differential diagnosis from small cysts. The diagnosis is more difficult 
when acute oophoritis develops after a tubal disease, or when it accom- 
panies an acute perioophoritis. As it is difficult in these cases to pal- 
pate the ovary separately, and the sensitiveness cannot be referred 
to the ovary alone, the most important symptoms are absent; never- 
theless, involvement of the ovary may be assumed if the adnexal dis- 
ease consists chiefly of a large and approximately round tumor. The 
cause is gonorrheal, septic, or tuberculous infection. Until pus can be 




Fig. 173. — Dermoid Cyst of the Ovary (after Pfannenstiel). In the centre of the tumor is the hirsute, dermoid 
core ; to the left, the 'anlage' with two prominent dental sacs, and around them a few spicules of bone. 



obtained, the diagnosis of gonorrhea depends on the clinical and patho- 
logic demonstration of uterine gonorrhea. Tuljerculosis may be assumed 
if other foci of the disease are found in other parts of the body. Septic 
infection (chiefly streptococcal) is indicated first of all by the existing 
possibility of infection (puerperium, operation, local uterine manipu- 
lations), and by continued febrile movements, particularly when 
associated with menstruation. 

The frequency with which the diagnosis of chronic oophori- 
tis is made by physicians is greatly in excess of the actual frequency 
of this disease. Even more than in acute oophoritis, it is absolutely 
necessary to isolate the diseased ovary by palpation, and a diagnosis 
of oophoritis based solely on the fact that pain is produced by external 



SPECIAL DIAGNOSIS 



335 




Fig. 174. — Ovarian Fibroma fafter Gebhard). CSpecimen from 
the Kgl. Uni\'er.sitats-Frauenklinik in Berlin.; 



pressure in the ovarian region must be rejected. If the ovary can 
be palpated by itself, if involvement of the peritoneum can ]h', posi- 
tively excluded, if there are no exudates or adhesions, the diagnosis 
is based in the main on 
two factors: enlargement 
and sensitiA^eness of the 
ovary; but these factors 
must both be present to 
establish the diagnosis. En- 
largement of the ovary 
occurs by thickening of the 
stroma, or dilatation of the 
follicles, or both, and affects 
all parts of the organ 
uniformly. The ovary is 
usually as large as a pig- 
eon's egg, rarely attaining 
the size of a hen's egg. The 
enlargement is constant in 
chronic oophoritis, in con- 
tradistinction to the tem- 
porary enlargements which 

are produced in the normal ovary by the formation of follicles and 
corpus luteum. The consistency is hard, often tense, but in no sense 
characteristic; as the same process is observed in small dermoid cysts, 

whereas small retention-cysts are 
more distinctly fluctuating. The 
surface is occasionally nodular 
or mamillated from the presence 
of small cystic degeneration fol- 
licles; hence enlargement and 
consistency alone are not suffi- 
cient for a diagnosis; they must 
be associated with another symp- 
tom — pain on pressure. But 
the value of a subjective symp- 
tom like pain on pressure is very 
uncertain on account of the 
individual differences in sensitiveness, as well as the differences in the 
degree of pressure used at the examination. It must also be remem- 
bered that normal ovaries may be somewhat painful, and that peri- 
metritic and parametritic processes may simulate ovarian pain on 
pressure or sensitiveness. Severe pain distinctly localized in the ovary 




Fig. 17.".- J n;l:riSARrOMA OF THE OVARY. 

(Original.; (.Specimen from the Kgl. Universitats- 
Frauenklinik in Konigsberg.) 



336 GYNECOLOGICAL DIAGNOSIS 

is a valuable symptom, but by itself it also is insufficient because 
nervous sensitiveness, so-called ovarism, neuralgia of the ovary, is not 
a rare condition. It follows, therefore, that the combination of distinct 
sensitiveness with constant enlargement of the ovary must be regarded 
as the most positive sign of chronic oophoritis. 

The diagnostic difficulties are considerably increased when chronic 
oophoritis occurs in connection with tubal diseases, perioophoritis, and 
parametritic exudates. The sensitiveness in these cases must never be 
attributed to the ovary alone and, as the gland cannot be palpated 
separately, it is not possible to recognize any existing enlargement. 
In most cases of chronic adnexal tumors it is safe to assume the 
existence of inflammatory processes in the ovary also. 

The symptoms are so indefinite or so general that they are 
of no value for the diagnosis of chronic oophoritis. Radiation of 
the pain into the thighs is more frequently observed than in other 
inflammatory processes. 



SPECIAL DIAGNOSIS 



337 



Diagnosis of Malignant Diseases of the Uterus. 



I. Carcinoma of the Uterus. 

Classification. Carcinoma of the uterus develops in the 
mucous membrane, or immediately underneath the membrane from 
its elements. The mucous membrane is therefore properly taken as 
the starting-point for the classification, and, in agreement with Ruge 
and Veit, wc distinguish the following varieties: 

1. Carcinoma of the vaginal portion. 
This originates in the mucous membrane which 
covers the vaginal portion, i.e., from the external os 
to the insertion of the vaginal vault (Fig. 17G, red). 

2. Carcinoma of the cervix, originating 
on the mucous membrane between the external 
and the internal os (Fig. 176, transverse shading). 

3. Carcinoma of the body, originating 
in the uterine mucous membrane from the internal 
OS to the tubal orifices (Fig. 176, blue). 

This classification is justified not onl)^ by 
the differences in the histologic pictures of carci- 
nomata, which correspond to the structure and 
character of the several segments and the mucous 
membrane from which they originate; but also by 
the differences in the clinical findings and the lines of extension followed 
by the individual forms. It is obvious, of course, that the division, 
especially that of carcinoma of the vaginal portion and of the cervix, 
can only be carried out during the early stages. The classification 
of carcinomata is important because not only the clinical picture of 
cancer, but the methods of diagnosis also are entirely different, 
depending on the starting-point and extension of the carcinoma. 

The diagnosis of uterine cancer is based on the objective demon- 
stration of the changes produced by the neoplasm at the point of origin 
and in the immediate neighborhood; hence before discussing diagnostic 
methods, I shall give a fuller description of these alterations. 




Fig. 176. — Normal Uter- 
us, Showing the Different 
Segments of the Mucous 
Membrane. (Schematic.) 
(Original.) 



Clinical Pictures and Lines of Extension of Cancer of the Uterus. 

I. Carcinoma of the Vaginal Portion. The carcinoma represents a 
neoplasm which more or less rapidly undergoes degeneration. The 
neoplasm may grow from the vaginal portion into the lumen of the 



338 



GYNECOLOGICATv DIAGNOSIS 




Fig. 177. — Cauliflower Cancer of the Vaginal 
Portion, Amputated above the Vagina. (From a 
preparation in tlie Kgl. Universitats-Franenklinik in 
Berlin.) j. (Original.) 



vagina antl appear as a tumor projecting from that canal; or it may 
grow into the tissue of the vaginal portion and produce infiltration. 
Depending on whether the neoplasm degenerates rapidly or slowly, 
infiltration or ulceration will predominate. In this manner various 

clinical pictures arc produced, 
a sharp differentiation of which 
is important in a diagnostic 
sense, although it must be 
admitted that they merely rep- 
rrsent different stages of the 
same variety developing side 
by side, not different forms of 
carcinoma. We distinguish: 

1. Polypoid carci- 
noma of the vaginal portion. 
This so-called cauliflower car- 
cinoma represents a tumor of 
tlie vaginal portion, originating 
either in both lips, or in only one li]), or only part of one lip, and 
quite frequently in the commissure. The tumor may be broadly sessile 
and attached to the entire width of the vaginal portion, or merely to 
the periphery, forming a pedunculated tumor; the pedicle is rarely 
smaller than one finger; the size is ciuite variable, from that of a hazel- 
nut to that of the fist, in the latter 
case filling the entire lumen of the 
vagina. The parts of the vaginal 
portion not affected by the carci- 
noma are hidden behind the cauli- 
flower and often difficult to find; 
the surface of the tumor is never 
smooth; usually nodular, uneven, 
rough, and friable (mortarlike). In 
rare cases the surface is red; but 
usually it is covered with a greasy, 
gangrenous mass (Figs. 177 and 178). 
2. Infiltrating carcinoma 
produces thickening and hardening 
of the tissues of the vaginal portion, forming a ring around the entire 
structure, or leaving one lip or part of one lip free; the depth to 
which the infiltration extends into the tissue is variable, but rarely 
goes beyond the insertion of the vaginal vault. The surface shows 
small, insignificant ulcers; in rare cases the mucous membrane may 
be quite intact (Fig. 179). 




Fig. 178. — Pedunculated Cauliflower Can- 
cer OF the Vaginal Portion. (From a specimen ia 
the Kgl. Universitats-Frauenklinik in Berlin.) |. 



SPECIAL DIAGNOSIS 





3. A care i n orn atou.s cavity in the vaf^inal fjortir,ri is a funncl- 
shaporl cavity produced by ulceration, usually corresponding to one lip, 
and involving the tissue of the vaginal portion almost to the interior os. 
The cavity runs parallel to the cervical canal and external os, and 
often ascends along with \]\<- lower portiorj of the cervical canal (Fig. ISO). 

4. Carcinomatous ulcer is a flat ulceration on the surface 
of the vaginal portion, showing no tendency to 

extend downward into the tissues and spread- 
ing only on the surface; it is usually limited to 
one lip of the cervix (ulcus rodens) (Fig. 181). 
Lines of extension. Pure carci- 
noma of the vaginal portion regularly extend. - 
along the surface toward the vaginal vault, 
and from there to the walls of the vagina, 
extension to the cervical mucous membrane 
being rarely observed. Cauliflower canceih 
and carcinomatous ul- 
cers have the greatest 
tendency to spread to 
the vagina, and chiefly 
attack the surface of 
the vaginal wall which 
adjoins the diseased lip. 
Carcinomata which pen- 
etrate the substance of the vaginal portion are 
more inclined to spread in the submucous tissue 
of the vagina, and lead to infiltration, which at 
first is covered with mucous membrane, in the 
form of a circular infiltration; they advance 
slowly toward the introitus and are always deepest 
in the anterior, and highest in the posterior wall. 
Occasionally metastatic nodules appear under- 
neath the mucous membrane, their favorite seat 
being the posterior wall of the fold surrounding the urinary meatus. In 
rare cases so-called contact cancers, i.e., carcinomatous changes in those 
parts of the vaginal wall which are in contact with the primary cancer, 
are encountered. Extension to the cervical tissue is most frequently 
seen in the infiltrating forms. The extension is continuous, /,;«<« of 

or, in extremely rare instances, discontinuous bj^ leaps, and ^-^^u:I•m^m. 

goes on to a variable distance, rarely as far as the internal os, and only 
in extreme cases beyond that point. Occasionally the cervical mucoas 
membrane becomes infected from behind. The body of the uterus is 
attacked only in the very' last .stages, and then only by continuous 



Fio, 179. — Isnr/riix'nso Cabci- 

NOMA OP THK VaOISAI. PoKT/O.V, J^. 

CSpecimen from the Kgl. Uriiverei- 
tiits-Fraiieiikliriik in iieriin.j 



Fig. 180. — Cabcxvoma- 
Tors Cavity in thk Vaoinai, 
Portion, (From a speci- 
men in the Kg]. LTniversi- 
tiitij-Frauenklinik in Berlin.; 
Yi. (Origjnal.; 



340 



GYNECOLOGICAL DL\GNOSIS 



growth of the cancer. Discontinuous spreading in the form of metas- 
tases very rarely occurs in the tissues of the body and has as yet never 
been observed in the mucous membrane. According to Seehg, early 
involvement of the body by way of the lymph vessels is probable. The 
pelvic connective tissue is reached by way of the vagina, or the periphery 
of the lowest segment of the supravaginal portion. The extension of 
the carcinoma in the lymph clefts in the pelvic connective tissue is 
determined by the architecture of the parametrium; it takes place most 
frecjuently in the posterior segments of the lateral parametrium, which 
are situated laterally and in front of Douglas' folds, and goes as far as 
the pelvis. The anterior segment of the parametrium and the portion 

on each side of the bladder almost always 
escape. The thick layer of the parame- 
trium between the cervix and the bladder, 
and posteriorly between the cervix and the 
peritoneum, afford little room for the 
spread of the cancer. Infection of the 
pelvic connective tissue usually takes place 
by continuity in the form of an infiltration 
which is continuous with the diseased 
parts of the portio vaginalis or of the 
vaginal vault; as the result of breakdown 
they are soon converted into large cavities 
opening toward the vagina; rarely they 
produce large tumors in the parametrium. 
Occasionally the infection spreads in the 
lymphatics, converting them into hard 
cords which run to the pelvis. 
The bladder is reached quite late, either through the anterior 
vaginal vault or the supravaginal portion of the anterior cervical wall; 
while the rectum is involved comparatively rarely by way of the pos- 
terior parametrium. Extension by continuity to the peritoneal 
cavity also takes place comparatively late. 

The lymph glands affected in carcinoma of the vaginal portion 
are the hypogastric and iliac, rarely the sacral glands. 

The internal organs are attacked very rarely and very late 
in carcinoma of the vaginal portion, the lungs and the liver more 
frequently than &ny other. 

II. Carcinoma of the Cervix, Carcinoma of the cervix has its origin in 
the mucous membrane of the cervix, or the elements lying underneath in 
the cervical tissue. The cancer grows in a variety of wa3'S in the cervical 
substance, and infiltration alternates with degeneration, so that from the 
diagnostic standpoint the following clinical pictures are differentiated: 




Fig. 181. — Carcinomatous Ulcer 
(ulcus rodens), Involving the Left 
Commissure, the Posterior Lip, and 
THE Adjoining Vaginal Vault. (From 
a preparation in the Kg!. Universitats- 
Frauenklinik in Berlin). {. (Original.) 



SPECIAL DIAGNOSIS 



341 



Infiltrating 
Carcinoma. 



1. Infiltrating carcinoma represents a thickening of the 
entire cervix or of one wall; or it may form nodes in the cervix and 
cause a partial enlargement of the structure At first 
there is no ulceration, and the node is everywhere covered 
with intact mucous membrane. This gradually becomes thinner, infection 
takes place from behind, and the node finally breaks down (Fig. 182). 

2. A carcinomatous cavity in the cervix results from rup- 
ture of an infiltrating carcinoma that has 
undergone degeneration, or when a superficial 
carcinoma penetrates into the tissues at one 
point and rapidly undergoes degeneration. 
The cavities occupy the cervix and com- 
municate with the cervical canal, and in rare 
cases also with the vagina. The cervical 
canal is usually crowded against the sound 
wall and part of it merges with the cavity. 

3. Carcino- 
ma t o u s u 1 c e r - 
a t i o n within 
the cervical 
canal (internal 
cervical carcino- 
ma) begins in 
every part of the 
mucous mem- 
brane lining the entire canal, and at the 
same time penetrates but a short distance 
into the tissues and rapidly breaks down. 
The cervical canal enlarges to form a cavity 
of the wall of the cervix, and in many cases 
is not infiltrated at all but becomes grad- 
ually thinner from within outward; while 
in other cases infiltration is more marked and goes on hand in 
hand with the degeneration toward the canal (Fig. 184). 

Lines of extension. Continuous extension of cervical car- 
cinoma along the surface takes place exclusively toward the uter- 
ine body, the internal os off'ering no obstacle to the progress of the 
cancer. In superficial carcinoma of the mucous membrane jjnes of 

(3) particularly, the disease often secondarily involves the Extension. 

entire inner surface of the uterus. The body may also become in- 
volved by direct spreading of the carcinoma in the substance of the 
uterus, successive portions of the body becoming infiltrated and under- 
going degeneration until they form part of the cavity. Metastases 





Fig. 182. — Infiltrating Carci- 
noma OF THE Cervix. %. {Speci- 
men from the Kgl. Universitats-Frau- 
enklinilc in Berlin.) 



Fig. 183. — Carcinomatous Cav- 
ity IN THE Cervix, Resulting from 
Degeneration of an Infiltrating 
Carcinoma. %. (Specimen from 
the Kgl. Universitats-Frauenklinik in 
Berlin.) 



342 



GYNECOLOGICAL DIAGNOSIS 




are not infrequent both in the substance and in the mucous membrane 
(Fig. 185). The inner surface of the cavity is rough from the presence 
of papillary proliferations, nodular thickening and projection of the 
walls; the walls of the cavity are hard and thickened, depending on 
the degree of infiltration; at the beginning of degeneration the cavity 
is represented merely by a broad cleft in the midst of the infiltrated 

tissue. Extension to the vagina on the sur- 
face of the mucous membrane, over the external 
OS, never takes place. On the other hand, in 
advanced cases the neoplasm, as in carcinoma 
of the cervical portion, extends into the sub- 
mucous tissue, making its way gradually down- 
ward, preferably along the anterior wall; metas- 
tases in the vaginal 
mucous membrane 
are rare. The pel- 
V i c c o n n e c ti V e 
tissue is attacked 
from the periphery 
of the cervix first at 
the point where the 
carcinoma has pene- 
trated most deeply; 
it becomes involved latest in superficial 
mucous membrane carcinomata, and earliest 
in the presence of deep infiltration of one 
wall; extension within the pelvic connective 
tissue takes place in the same way as in 
carcinoma of the vaginal portion. The 
bladder early becomes involved in the 
morbid process, particularly in the case of 
carcinoma of the anterior wall; while the 
rectum is not attacked until the disease 
has become quite extensive in the pelvic 
connective tissue. The peritoneal cavity long resists the infection; 
the iliac glands are the first to suffer. Metastasis to internal 
organs occurs in the same way as in cancer of the vaginal portion. 
IIlo Carcinoma of the Body. Carcinoma of the uterine 
body always begins in the mucous membrane and mani- 
fests itself in three different ways, depending on the extent of the part 
that is primarily diseased. 

1. Diffuse carcinoma results from uniform disease of the 
entire corporeal mucous membrane. Nodular thickening or villous 



Fig. 184. — Ulcerating Car- 
cinoma Beginning in the Mucous 
Membrane of the Entire Cer- 
vix. %. (Specimen from the 
Kgl. Universitats-Frauenklinik in 
Berlin.) (Original.) 




Fig. 185. — Ulcerating Cervical 
Carcinoma behind the Closed Ex- 
ternal Os or A Nullipara, with 
Metastasis in the Body. %, 
(Original.) (Specimen from the Kgl. 
Universitats-Frauenklinik in Konigs- 
berg, Prussia.) 



Carcinoma 
of the Body, 



SPECIAL DIAGNOSIS 



343 




Fig. ISfi. — Diffuse Carcinoma of the Uterine Body. % 
(Specimen from the Kgl. Universitats-Fiauenklinik in Berlin.) 



proliferations form on the mucous membrane; the wall slowly becomes 
infiltrated, and the accompanying inflammatory reaction leads to thick- 
ening of the entire uterus, until finally the carcinoma emerges from the 
outer surface of the uterus 
in the form of large or small 
nodes and grows toward the 
abdominal cavit}^; the uter- 
ine cavity dilates as the 
result of breakdown of the 
neoplasm (Fig. 186). 

2. Circumscribed 
carcinoma results from 
disease of a circumscribed 
portion of the uterine wall, 
the rest of the uterus re- 
maining absolutely healthy. 
In rare cases the affected 
portion is smaller than a 
mark (quarter of a dollar). The neoplasm appears in the form of 
nodular tumors with irregular, rough or villous surface, or a circum- 
scribed ulceration surrounded by infiltrated tissue (Fig. 187). 

3. Polypoid carcinoma is very rare 
and usually secondary. The polyp is usually 
attached by a thin pedicle to a Poiypoid 

circumscribed portion on the carcmoma. 

uterine wall and distends the cavity as it 
grows. The tumor is soft, friable, and breaks 
down on the surface; it does not extend 
far down into the tissues; the remainder of 
the mucous membrane is healthy, or at most 
ulcerated at the surface as the result of 
inflammation (Fig. 189). 

Lines of extension. Within the 
uterus itself the cancer grows either chiefly 
into the uterine wall or toward 
the cavity. Carcinomata that 
have a tendency to grow toward the free 
cavity produce less infiltration of the wall 
(Fig. 182 and 188), while those which spread 
toward the uterine wall rarely lead to the formation of large neoplasms 
within the cavity (Fig. 186). The tendency to spread on the surface 
is not very great. Primary diffuse carcinomata are the only ones 
that occasionally overstep the internal os and spread toward the 




Lines of 
Extension. 



Fig. 187. — Circumscribed Carci- 
noma OF the Uterine Body. %. 
(Specimen from the Kgl. Universitiits- 
Frauenklinik in Berlin.) 



344 



GYNECOLOGICAL DIAGNOSIS 



cervix. As a rule they are arrested at the internal os. Extension 
downward into the tissues meets with much less resistance, but 
the process is slow and it takes a long time before the entire wall 
becomes completely infiltrated. In the pelvic connective tissue 
the disease may be limited to the broad ligament proper if the carci- 
noma reaches the periphery of the uterus exactly 
in the lateral aspect or if the disease attacks the 
areas between the muscles and the loosely attached 
peritoneum. From this point infection takes 
place in the form of nodular thickening. The 
deep portion of the parametrium can be infected 
only Ijv way of the cervix. The peritoneum 
over the entire outer surface of the body may 
become diseased if 
the carcinomatous 
nodules extend so 
far. Adhesions with 
adjacent organs, 
omentum and intes- 
tine, form at these 
points, or with the 
parietal peritoneum. 
In this way the tu- 
mor becomes adhe- 
rent to the intes- 
tines, and , perforation may take place. 
The bladder and rectum are attacked 
very late. The glands which become 
involved in carcinoma of the body are the 
lumbar glands, situated on the vertebral 
column around the aorta; very rarely the 
inguinal glands become involved by way of 
the lymphatics which reach the inguinal 
canal along with the round ligament, if the 
carcinoma develops in that portion of the 
uterus which is drained by these vessels. 

The ovaries not infrequently become the seat of metastasis, probably 
by way of the lymphatic anastomoses. Metastasis to internal organs 
is practically the same as in cancer of the vaginal portion and cervix. 




Fig. 188. — Circumscribed 
Carcinoma in a Small Senile 
Uterine Body. ^i- (Orig- 
inal.) (Preparation from the 
Kgl. Universitats-Frauenkli- 
nik in Berlin.) 




Fig. 189. — Polypoid Carcinoma of 
THE Uterine Body. Metastasis from an 
ovarian carcinoma. (From a specimen in 
the Kgl. Universitats- Frauenklinik in 
Berlin.) }. (Original.) 



Diagnosis and Differential Diagnosis of Cancer of the Uterus. 

The diagnosis of cancer of the uterus involves more responsibility 
than any other. Every mistaken diagnosis, and even a delayed diag- 



SPECIAL DIAGNOSIS 345 

nosis, costs a human life, because the cancer may in the meantime have 
become inoperable. The physician must, therefore, make every effort 
to recognize the cancer correctly at the first examination, under all 
circumstances and with the employment of every known diagnostic 
aid. Among the aids which are within the reach of the practising 
physician I include also consultation with an experienced colleague. 
The practice of keeping under observation a patient presenting sus- 
picious symptoms of cancer in the hope that the destructive tendency 
of the growth may show itself, as was formerly done, cancer 

must at the present time be regarded as a technical error. Symptoms. 

A positive diagnosis can only be made by objective examination; nev- 
ertheless, there are a number of symptoms, so-called symptoms 
of cancer, which render the diagnosis very probable. The relation 
of these symptoms to the diagnosis is peculiar. They do not confirm 
the diagnosis, but merely help to indicate that a carcinoma is prob- 
ably present. If the symptoms are found, an accurate examination 
must under all circumstances be made, with the special object of seeking 
the cause of the sj'mptoms in a cancer. 

The routine examination of every patient who consuUs a physician on account of gyne- 
cological symptoms would offer the surest means of recognizing cancer in time; but for vari- 
ous reasons, already explained, it is impossible to adopt such a policy in practice. Under all 
circumstances, however, the physician should insist on making an internal examination at 
once if there is the slightest suspicion of cancer. Nothing should deter him from making 
such an examination — neither lack of time, nor his own convenience, nor lack of confidence 
in his technique or ability to make a correct diagnosis, nor even the fact tliat the patient 
happens to be bleeding. Every neglect to make an examination delays the diagnosis, particu- 
larly as the patient herself makes enough objections to tlie examination as it is. Some women 
are ashamed, or afraid of pain; others dread a serious diagnosis or the physician's counsel to 
undergo an operation; others resort to any excuse that occurs to them in order to escape the 
hated examination. If the physician listens to these objections or is unable to overcome 
them, the examination is put off, and a loss of time which may be dangerous to the patient 
is incurred. The physician must be anxious to examine and must be able to overcome the 
patient's objections and l^end her to his will; his will-power will be strengthened by a sus- 
picion that a given case may possibly be a cancer, and this suspicion is aroused by a knowl- 
edge of the symptoms of carcinoma. In this sense, the symptoms of carcinoma play an 
important part in the diagnosis. 

The symptoms of carcinoma are bleeding after coitus, 
caused by mechanical injury of the carcinoma, or engorgement of the 
vessels during coitus and subsequent rupture. It is very common and 
not infrequently the first symptom noted in cancer of the cervix, and 
although it occurs occasionally with hyperemic erosion, endometritis 
accompanied by severe bleeding, or with polyps, it should always arouse 
the suspicion of cancer. Of equal importance is metrorrhagia 
after the menopause, at least if it occurs several months after the ces- 
sation of the menses. While this symptom is not exactly pathogno- 
monic of cancer, as it also occurs in myomata and polypoid disease of 



346 GYNECOLOGICAL DIAGNOSIS 

the vessels when the mucous membrane is very thin and easily injured, 
it is nevertheless in the great majority of cases due to cancer. Inegular 
hemorrhages without any connection with menstruation are quite 
common in cancer, but occur in so many other diseases also that they 
cannot be regarded as a particularly important symptom of carcinoma; 
nevertheless, they are an indication for examination, and the older the 
woman the greater the probability that a cancer will be found. Special 
kinds of vaginal discharge also point to cancer. A necrotic, bloody 
discharge with tissue debris is rather characteristic of rapidly degener- 
ating carcinoma and is of little value for early diagnosis; but a 
serous sanguinolent flow, resembling beef brine, occurs in the 
very early stages of cancer of the cervical portion and is rare in any 
other condition. 

I have frequently had occasion to observe that among inexperi- 
enced physicians two factors play a quite unjustifiably important role 
in the diagnosis of cancer; the cancerous cachexia and the well-known 
'forty years.' Against these I wish to sound a special warning. Ca- 
chexia occurs only in very late stages, and is therefore of no value for 
an early diagnosis; and the age is neither in favor of nor against the 
diagnosis of cancer, as the disease may occur at any period of life, from 
twenty years to extreme old age. 

The clinical diagnosis of cancer of the uterus is based on the dem- 
onstration of its two chief characteristics, — the neoplasm and degenera- 
tion. The former appears in the form of proliferations on the surface, 
Physical 01" infiltration of the ground substance. The. latter begins 

^'°"''' on the surface and leads to softening of the newly formed 

tissue; or it begins in the centre of the infiltration, which ruptures, with 
the formation of a large carcinomatous cavity. The tendency of carcino- 
matous tissue to undergo central and peripheral degeneration is respon- 
sible for a peculiarity which has great diagnostic value, namely, the 
friability of the tissue. It is recognized by the sound penetrat- 
ing the tissue, and by the fact that the slightest pressure with the finger 
destroys and breaks it up. This property of breaking up into small 
pieces under the influence of pressure is observed in no other tissue, 
except possibly in myomata in a state of advanced degeneration, in 
which I have seen a similar phenomenon. Another property of exposed 
carcinomata, which may occasionally be of diagnostic value, is their 
tendency to bleed at the slightest touch. A carcinoma of the vaginal 
portion bleeds whenever it is touched somewhat roughly with the 
sound, with the edge of a speculum, or even when the vaginal walls are 
separated for the purpose of inspection. The same is true of cervical 
carcinoma. In carcinoma of the body sounding is often followed by 
hemorrhage of considerable severity. As, however, hemorrhage is 



SPECIAL DIAGNOSIS 347 

produced by the same causes in cases of erosion, endometritis, and 
polyp — although the bleeding is less profuse — a diagnosis cannot be 
based on this sign. When the two peculiarities of cancer — neoplasm 
and degeneration — are distinctly present, the diagnosis is easy; but if 
one of them is absent, i.e., if there is proliferation or infiltration without 
degeneration, or if the base of the ulcer is not infiltrated, the diagnosis 
may be very difficult and clinically impossible. In order to demonstrate 
these two clinical properties of cancer we resort to palpation and in- 
spection, which are both important methods, but not in the same degree. 
A beginning cancer, particularly of the vaginal portion, is often more 
easily recognized by inspection, and therefore requires careful examina- 
tion with the speculum. In advanced cancer, on the other hand, the 
signs obtained by palpation are usually very marked, while inspection 
may be deceptive because subvaginal infiltration can be felt, but cannot 
be seen, and the wall of infiltrated tissue often hides the carcinomatous 
cavities from view. In such cases inspection must always be combined 
with palpation. It is obvious that the diagnosis of a uterine cancer is 
easier the more readily it is accessible to the finger and to the eye. 
If the cancer is situated in the outer surface of the vaginal portion, 
or if the os is dilated and the finger can be introduced into the cervix, 
it is usually easy to feel an ulceration and infiltration; whereas, if the 
cervix is closed and the neoplasm is situated in the body of the uterus, 
it is impossible to demonstrate its presence by palpation and inspection. 
Hence the methods employed for the diagnosis of cancer must be varied 
according to the seat and development of the neoplasm. If clinical 
methods of examination fail to yield a positive result, resort must be 
had to microscopic examination of the diseased tissue. 

I. The Diagnosis of Cancer of the Vaginal Portion. 

The diagnosis is easiest in this situation because the changes are 
readily recognized by touch and sight. This is particularly true of the 
cauliflower tumors, which project like polyps from the sub- 
stance of the vaginal portion, especially if the surface of 

1 •!! Tr-11 • 1-ci Diagnosis; 

the tumor is broken down. Ir the latter is rough, u the 
tumor breaks up easily and yields to the pressure of the finger, and if 
the sound penetrates the tissue without any trouble, the condition is 
unquestionably carcinoma. If the carcinoma is flat and situated on 
the outer surface of the vaginal portion, any proliferation beyond the 
level of the mucous membrane is suspicious (Fig. 190). As a rule, 
these carcinomatous portions also differ from normal tissue by their 
greater hardness. If the neoplasm is situated within the substance 
of the vaginal portion, in other words, in cases of infiltrating 
carcinoma^ a cartilaginous consistency of the growth is character- 



348 GYNECOLOGICAL DIAGNOSIS 

istic; at the same time, the shape of the portio vaginahs is altered and 
the structure becomes broad and shapeless. These changes are most 
easily recognized if they are confined to individual portions, while in 
the others the shape and consistency remain normal. So long as the 
carcinoma is covered with intact mucous membrane the diagnosis is 
exceedingly difficult, although the surface has a peculiar bluish tint 
and exhibits scattered yellow areas corresponding to cancer-nests 
that have undergone fatty degeneration. As soon as ulceration begins 
in the surface, all doubt disappears. Carcinomatous ulceration 
of the vaginal portion is easily recognized by the cavities with uneven, 
rough and ragged walls which are produced. If the surrounding tissue 
is hard, the changes are so characteristic that the diagnosis can be 
made by a single touch; but if the cavity is not large enough to admit 




Fig. 190. — Beginning Cauliflower Cancer on the Anterior Lip of the Vaginal Portion. (Original.) 

the finger, beginning degeneration can nevertheless be seen in the 
speculum. Instead of the smooth mucous membrane of the vaginal 
portion one sees fissures with sharp jagged edges, often covered with 
a yellowish exudate; or the normal border of the os is replaced b}'' a 
ragged ulcer (Fig. 191). In these cases also the deeper degeneration 
can be recognized by the want of resistance in the tissues when the 
suspicious spots are tested somewhat vigorously with the finger, or by 
the fact that the sound penetrates the tissue without any difficulty; 
or pieces can easily be removed with the curette. Friability of the 
tissue is always suspicious of cancer. The most difficult cancers to 
recognize are those which appear in the form of flat ulcers, because 
numerous other processes also produce flat ulcerations in the vaginal 
portion. The characteristic features of carcinomatous ulcer are its 
sharp, and in places jagged border; bright red, or, in the presence of 
degeneration, yellowish-gray, slightly nodular surface; and the moderate 
depth and infiltrated floor of the ulcer. 



SPECIAL DIAGNOSIS 349 

In a considerable number of cases the above-mentioned clinical 
signs are not sufficient for a positive diagnosis. In such cases a piece 
is excised from the suspicious spot and the diagnosis is made by the 
histologic picture. The ability to make a correct diagnosis in rare 
cases of this kind, without resorting to the microscope, grows in direct 
proportion with one's clinical experience. A physician with limited 
experience ought, if he were in the habit of making accurate exam- 
inations, to see a great many doubtful speculum pictures and feel a 
suspicious hardness in a great many cases; and for this reason, he 
ought to resort more to the microscope in the diagnosis of cervical 
cancer than the expert specialist. 




Fig. 191. — Carcinomatous Ulceration of the Vaginal Portion. (Original.) 

A number of different conditions must be considered in the 
differential diagnosis, depending on whether the cancer to be differ- 
entiated belongs to the polypoid, infiltrating, or ulcerating form. 

Polypoid carcinomata (cauliflower tumors) may give rise to con- 
fusion with the rare forms of papillary tuberculosis of the vagi- 
nal portion, which also lead to proliferation in both lips of the external 
OS. On account of their irregular surface and infiltrated floor they 
may closely resemble a cauliflower tumor. Occasionally Poiypoid 

the characteristic elements of tuberculosis are seen either Carcmomata. 
in the neoplasm itself or in the immediate neighborhood, as in the 
shape of pearly nodules the size of a millet seed; and in the intervals 
between these nodules is seen the caseous greasy material which results 
from the breaking down of tuberculous tissue. The differential diag- 
nosis can, therefore, be made only after very careful inspection. Quite 
often the diagnosis remanis in doubt and a microscopic examination 



350 



GYNECOLOGICAL DIAGNOSIS 



must be made, by means of which tubercle nodules, and frequently also 
bacilh, are found in the excised piece of tissue. Occasionally the demon- 
stration of tuberculosis in the tubes and in the peritoneum, or the finding 
of a tuberculous focus in other organs, may make the diagnosis possible. 




Fig. 192. — Multiple Mucous Polyps of the Cekvix. (Original.) 

Gaebel mentions a papillomatous tumor of the vaginal portion which was very like a 
cauliflower cancer and which owed its origin to infiltration with the ova of Bilharzia. The 
absence of discharge, of ulceration, and of infiltration in the neighborhood, according to this 
author, suffices to guard against mistaking the condition for a cancer. 




Fig. 193.- 



-FoLLicuL.^R Polyp from the Posterior Lip of the Cervix. (Original.) (Ovula Nabothi 
on the anterior lip and surrounding the external OS.) 



Occasionally mucous polyps of the cervix, filling the entire 
external os, may resemble a cancer if the surface is nodular. On close 
inspection, however, the surface is found to be smooth and covered 
with mucous membrane, and on careful sounding it is easy to demon- 
strate that they are composed of individual mucous polyps which 
originate in the cervix (Fig. 192). 



SPECIAL DIAGNOSIS 



351 



A cervical myoma with a broad pedicle may protrude from the 
vaginal portion. Such a tumor is distinguished from carcinoma by its 
smooth covering of mucous membrane, which may occasionally become 
gangrenous, and especially by its firm consistency and absence of friability. 

Follicular hypertrophy of the vaginal portion leads 
to the production of large tumors in circumscribed portions of the 
cervix. The surface is not rough or nodular, the consistency is not 
friable, and the tumors are covered with smooth mucous membrane, 
through which the dilated follicles can sometimes be seen. After rup- 
ture of the latter, irregular retractions are produced here and there on 
the surface, as in the tonsils. In these cases the microscope occasionally 
has to be consulted (Fig. 193). 

Acuminate condylomata may simulate a carcinoma of the 

vaginal portion if, as occurs 
most frecjuently during preg- 





FiG. 194. — Papilloma (condyloma acu- 
minatum) OF THE Vaginal Portion in a 
Pregnant Woman. (Original.) 



Fig. 19-5. — Erosion with Slightly 
Papillary Surface. (Original.) 



nancy, they are closely packed and represent a circumscribed tumor 
on the external surface. In such a case they form a true neoplasm 
with irregular surface, but the base is not infiltrated and there is no 
true ulceration, only a papillary surface with thick epithelium. The 
color is usually whitish-red. The diagnosis is simplified by the fact 
that the condylomata are found in other portions of the cervix or 
in the vagina and vulva fFig. 194). 

Infiltrating carcinomata are most likely to be confounded with 
inflammatory affections (metritis colli), particularly if the vagi- 
nal portion becomes nodular from the presence of lacerations or notches, 
or swelling of the parts betw^een. The inflammatory changes always 
affect the entire vaginal portion uniformly. The consist- infiltrating 

ency is not so cartilaginous and elastic as in the case of Carcmoma. 

carcinoma, and the cervix is covered with smooth mucous membrane. 
The palpatory findings are very similar to those obtained in carcinoma 



352 GYNECOLOGICAL DIAGNOSIS 

produced by infiltration of the vaginal portion with dilated follicles, 
particularly as the structures may have a nodular feel on account of 
the projecting follicles. The similarity is increased by the fact that 
these changes usually do not involve .the entire vaginal portion and the 
consistency may be very tense; but with the speculum it is seen that 
the structure is covered with smooth mucous membrane, with here and 
there follicles shining through, which on being punctured exude a 
tenacious mucus; in doubtful cases the microscope must be consulted. 
F3at carcinomatous ulcers without accompanying infiltration are 
often very difficult to distinguish from other ulcerations of the vagi- 
nal portion. It requires long clinical experience to be able to interpret 
an ulcer of the vaginal portion with certainty, and even the practiced 




Fir,. 196. — Simple Ulcer in Process of Cicatrization. (Oiisinal.) 

diagnostician is forced to consult the microscope more frequently than 
in any other condition. In order to show the difference from carci- 
nomatous ulcers (see page 348, and Fig. 101) I shall describe the 
clinical characteristics of other kinds of ulcers and similar processes. 
Erosions (Fig. 195) are in the main easy to distinguish from 
cancerous ulcers; they may resemble the latter, however, if they 
develop on a hard inflammatory base, if they are associated with ectro- 
pion, or their surface becomes rough and nodular by the formation 
of thick papillffi (erosio papillaris). Inspection with the spec- 
ulum decides the diagnosis. An erosion usually surrounds the external 
OS uniformly and, owing to its epithelial covering, has a reflecting 
surface and bright red color; while a carcinoma, even if the ulceration 
is quite superficial, is more dull in appearance and the surface is rougher. 
Erosions have no sharp edge and merge gradually with the squamous 



SPECIAL DIAGNOSIS 353 

epithelium of the vaginal portion; their outline is irregular, and on 
the surface islands of epithelial follicles, or follicular ulcers, are not 
infrequently seen. If the erosion has lost its epithelial covering, or 
purulent infection of the surface or incrustation with scabs has devel- 
oped, the diagnosis is more difficult. Under these circumstances the 
microscope occasionally has to be consulted. 

Decubital ulcer (Fig. 196) (ulcus simplex) occurs in cases 
of prolapse and forms irregular lacerated ulcers, often involving large 
portions of the vagina. The external os itself is often free from ulcera- 
tion, while in carcinoma this portion is usually attacked first. Decu- 
bital ulcers are usually separated by a sharp line from the thickened 
epithelium and the hypertrophied vaginal portion of the floor is ulcer- 
ated and often covered with a pale yellowish exudate. At the periphery 




Fig. 197. — Tuberculous Ulcer of the Vagixal Portiox. (Original.) 

cicatrization is often seen, and in the middle, islands of epithelium. 
In contrast with carcinoma, the floor of the ulcer is entirely free from 
infiltration, and a few days after replacement of the prolapse distinct 
signs of healing are observed in the form of peripheral epidermidalization. 
Decubital ulcers may also be produced in a normally situated vaginal 
portion b}^ the use of ill-fitting pessaries. These ulcers are immediately 
underneath the arch of the pessary, oval in shape, with a greasy fioor. 
They heal rapidly after removal of the pessary. The ulcers remaining 
after the separation of a piece of mucous membrane in croupous or diph- 
theritic processes, or after cauterization, differ from carcinomatous ulcers 
by the presence of the remains of gangrenous, white mucous membrane 
vv'hich still adheres to them, and the absence of all infiltration. 

Tuberculous ulceration (Fig. 197), we must admit, is 
exceedingly rare, and produces a picture very similar to that of carci- 
noma. It also surrounds the external os; the edges are sharp and 

23 



354 



GYNECOLOGICAL DIAGNOSIS 



frequently undermined, resembling tuberculous ulcer of the intestine. 
The floor of the ulcer is yellowish, slightly granular and uneven, but 
not infiltrated. On the floor of the ulcer, as well as in the surrounding 
tissue, yellow miliary tubercles are frequently seen. An important 
support to the diagnosis is found in tuberculous disease in other organs, 
particularly coincident tuberculosis of the uterus and tubes. The 
specific structures of tuberculosis and the tubercle bacilli, which are 
easily recognized in the microscopic picture, afford positive signs of a 
tuberculous disease. 




Fig. 198. 



-Chancroids on the Posterior Lip of the Cervix and Anterior Vaginal Wall (after 

Heitzmann). 



Chancroids (ulcera mollia) (Fig. 198) are usually small ulcers, 
sometimes becoming larger by confluence, with a slightly indented, 
somewhat elevated border. The floor of the ulcer is lardaceous 
and diphtheritic, but not infiltrated. The fact that the ulcers are 
multiple, the presence of contact ulcers and the simultaneous appear- 
ance of similar ulcers in the vagina, especially in the external genitalia, 
are all fairly characteristic of chancroid. 

Syphilitic ulcers occur in the vaginal portion in three dif- 
ferent forms: initial lesion (sclerosis), degenerated papule, and gumma. 
An ulcerated and degenerated primary sore (Fig. 199) is 
not rare in the vaginal portion. It is characterized by the fact that it 
is solitary and has a hard consistency at the base. On close inspection 



SPECIAL DIAGNOSIS 



355 



it reveals itself as a shallow ulcer with an indistinct border and dirty, 
brownish-red color, and the floor is sometimes covered with a greasy 
exudate. In multiparas with patulous external os the ulcer may 
extend far up into the cervical canal (Neumann). The anterior lip is the 
favorite site. Papulous ulcers (Fig. 200) are somewhat elevated 
above the level of the vaginal portion, and the surface is covered with 
whitish or yellowish, broken-down tissue. These ulcers are usually 
multiple, and along with them are seen other papules in the vagina 
and particularly on the vulva, which have not undergone ulceration. 
Gum mat a on the vaginal portion are exceedingly rare. Neumann 
describes them as ulcerations occurring in the neighborhood of the ex- 
ternal OS, both on the anterior and on the posterior lip, and often sur- 
rounding both lips at the same time. The ulcers which result from 

gummata are elliptical and sharply 
outlined, shallow, or somewhat 





Fig. 199. — Syphilitic Primary 
Sore on the Anterior Lip of the 
Cervix (after Neumann). 



Fig. 200. — Condylomata L.\ta 
ov the Vaginal Portion (after 
Stratz). 



depressed, and the floor is usually covered with a puriform exudate^ 
separation or removal of which often leaves a spongy granulation which 
bleeds freel3^ The distinction from carcinoma is based on their situa- 
tion to one side of the external os, the sinuous outline of the ulcer, 
rapid degeneration, crater-like depression, and peripheral extension 
with serpiginous border. In all specific processes the diagnosis is ren- 
dered very probable by the demonstration of specific affections in other 
places. The microscope will occasionally have to decide. The finding 
of spirochseta pallida particularly appears to afford positive support to 
the diagnosis. 

II. The Diagnosis of Cervical Cancer, 

The diagnosis of cervical cancer is more difficult, particularly if 
it is deeply situated in the cervical substance and is inaccessible to the 
palpating finger on that account, or because the os is closed. Cancers 
which have ulcerated and opened toward the outer surface of the 



356 GYNECOLOGICAL DL\GNOSIS 

vaginal portion are no more difficult to diagnose than ulcerating cancers 

of the vaginal portion itself; they are easily recognized by the rough, 

ragged friable walls of the cavity, particularly if the surrounding tissue 

is infiltrated. Similarly the diagnosis is easy in those cases 

Diagnosis _ _ ^ f^ ^ 

of Cervical in wliich tlic finger can be passed from the cervical canal 

Cancer. ... ... 

into the cavity, or the entire inner surface has undergone 
carcinomatous degeneration. In these cases also a nodular thick- 
ening, with rough surface and friable consistency, is felt. If the lower 
portion^ of the cervical canal can be seen in the speculum, the true 
nature of the ulcerative surface can be recognized by the absence of 
epithelium. The rough and sometimes greasy appearance of the lower, 
jagged edge of the ulcer just appears at the external os. The friable 
consistency of the wall is most easily demonstrated by means of the 
curette. If large pieces of tissue can be removed with the curette 
by gentle pressure, the tumor is undoubtedly a carcinoma. The 
microscope is rarely needed in such cases. 

Infiltrating cancers which occupy part of the cervical wall, but are 
everywhere covered with mucous membrane, are difficult to recognize. 
The diagnosis in such cases must be based solely on the change in shape 
and the consistency; the cervix becomes distended, thick and shape- 
less, sometimes only on the affected side, and the cervical canal is 
crowded over to the other side. The consistency is as hard as cartilage 
and often elastic. Infiltration of the supravaginal portion of the cervix 
is best recognized by rectal examination. If the carcinoma approaches 
the vaginal portion, the investing mucous membrane at this point often 
becomes distinctly bluish and shows yellow points which correspond to 
degenerated cancer nests. Quite often, however, the mucous membrane 
is bright red, loses its gloss, and the superficial layers are readily stripped 
off'. If the carcinoma comes still nearer the mucous membrane, the 
latter breaks down, the cancer is exposed, and the appearance becomes 
similar to that of a primary cancer of the vaginal portion. In these 
infiltrating carcinomata it often becomes necessary to excise a piece 
for microscopic examination. A completely closed os offers a serious 
obstacle to the recognition of cervical carcinoma, particularly the forms 
without marked infiltration of the cervix which ulcerate toward the 
cervical canal, and above all internal cervical carcinomata. From a 
diagnostic standpoint these cases occupy the same position as carcinoma 
of the body. Either an attempt is made to dilate the external os for 
the purpose of introducing the finger, or — a better plan — a piece of 
tissue is removed with the curette and examined under the microscope. 
As it is impossible to diff'crcntiate between these cases and carcinoma 
of the body clinically, it is better to curette the entire body at the same 
time, and conversely, in cases that suggest carcinoma of the body the 



SPECIAL DIAGNOSIS 357 

upper portion of the cervix should also be examined. I distinctl)^ 
remember two cases in which only the body of the uterus was curetted 
again and again, always with the result that only benign changes of 
the mucous membrane were demonstrated with the microscope, while a 
cancer was developing undisturbed in the upper portion of the cervix. 
Differential Diagnosis. The chief source of diagnostic errors is 
found in the infiltrating carcinomata. They may be confounded with 
metritic changes and follicular hypertrophy, the ph3^sical signs of which 
have been described on page 351. Interstitial my o mat a situ- 
ated in the wall of the cervix may also give similar palpatory signs. 
They also cause partial thickening of the cervical wall, but they are 
more round, more sharply outlined, and surrounded by soft tissue; 
whereas carcinoma, owing to its processes and the inflammatory reac- 
tion, merges more diffusely with the surrounding tissue. In doubtful 
cases the microscope decides. Ulceration is always in favor of carci- 
noma. Degenerated carcinomata of the mucous membrane may, in 
the absence of marked infiltration, give palpatory signs similar to those 
obtained in chronic cervical catarrh in old women. In this con- 
dition also the mucous membrane feels rough, uneven, and nodular, from 
the glandular depressions and thickening of the intervening portions of 
tissue. As a rule, however, the surface is not so ragged as in carcinoma, 
and in the speculum the normal sheen of the mucous membrane is 
observed. If the curette is introduced into the cervical canal for the pur- 
pose of testing the friability of the tissue, it does not bring away any part 
of this tissue. Here again the microscope must speak the last word. 

III. Diagnosis of Cancer of the Body. 

This diagnosis is often missed because the possibility of such a 
cancer is not thought of. Even if the physician recognizes the impor- 
tance of the above mentioned symptoms of carcinoma and examines 
the woman for cancer, he is often satisfied if he fails to 

Diagnosis of 

find one in the vaginal portion or in the cervix. It is true cancer of the 

. Uterine Body. 

that cancers of the body are less frequent than cervical 
cancers in the proportion of about one to fifteen, but they are never- 
theless frequent enough to demand a searching examination if sus- 
picious symptoms are present. These are somewhat more striking in 
this condition, particularly the hemorrhages, as most corporeal cancers 
develop after the menopause. Another very suspicious and almost 
pathognomonic symptom is found in Simpson's pains, i.e., regular, 
labor-like pains, lasting several hours, and recurring at a definite time 
of the day. But no matter how striking the symptoms may be, the 
diagnosis must always be based on objective examination. To begin 
with, it should be emphasized that there are no characteristic bimanual 



358 GYNECOLOGICAL DIAGNOSIS 

palpatory findings in cancer of the body. In the early stages the size 
of the uterus may be absolutely normal, and even a senile, atrophied 
uterus may contain a neoplasm. In the advanced stages the viscus is 
thicker, larger, more tense, and often distinctly nodular; but it does 
not materially differ from myoma or a metritic uterus. Even when 
the carcinoma forms protuberances on the outer surface of the uterus, 
the condition cannot be positively distinguished from a subserous 
myoma by the sense of touch. The diagnosis of corporeal cancer can 
be made only by means of an internal examination of the cavity. This 
is always begun with the sound. In circumscribed places, or on the 
entire inner surface, irregularities are found which occasionally differ 
from the irregularities formed by the retention of decidual tissue, or those 
seen in fungous endometritis, by their hardness, their nodular char- 
acter, and by the fact that they give the sensation as if the instrument 
were gliding over a projection and down into a depression. Occa- 
sionally one gets the impression that the head of the sound is penetrat- 
ing into the tissue. While these findings are never a proof of carcinoma, 
and should only serve to induce the examiner to resort to other methods 
of examination, carcinoma can practically be excluded with certainty 
if the entire endometrium is found to be absolutely smooth; if irregu- 
larities are found, a microscopic examination must follow. There is no 
objection to employing the microscope if the symptoms are very sus- 
picious, even if no roughness is discovered with the sound. Microscopy 
is the sovereign method in the diagnosis of corporeal cancer. Its use 
can be dispensed with only in those cases in which the cervix is open 
and the protruding mass is unquestionably carcinomatous, or digital 
exploration is absolutely conclusive. Digital exploration of the uterine 
cavity may give positive information in complicated cases. The finger 
encounters circumscribed or diffuse thickening in the uterine wall, or 
the hard infiltrated border and floor of a carcinomatous ulcer, or villous 
papillary proliferation filling the entire cavity, or tumors with rough 
surface and friable consistency. Small, soft, polypoid carcinomata 
are more difficult to recognize, and carcinoma of the mucous membrane 
in the earlier stages may entirely escape the exploring finger. In all 
cases in which the cervix opens spontaneously, digital exploration of 
the uterine cavity should be employed; but if there is the slightest 
doubt, or the findings are negative, an exploratory curettement for the 
purpose of microscopic examination must follow. If, however, the cervix 
is closed, the diagnosis should first be made by the result of exploratory 
curettage; and only if the microscopic diagnosis is not positive, should 
dilatation and digital exploration be employed. The advantages are 
all on the side of the former method, partly because exploration is 
more dangerous than curettage, and partly because the palpatory 



SPECIAL DIAGNOSIS 359 

findings arc much more likely to give rise to an error in diagnosis than 
a microscopic examination in the hands of an expert pathologist. 

The differential diagnosis in carcinoma of the body is therefore 
almost exclusively based on the histologic findings; if a digital explora- 
tion is employed, it must be remembered that sarcoma of the mucous 
membrane, degenerating myoma, mucous polypoids, and the remains 
of abortions may yield similar physical signs. From all these conditions, 
which are described in detail in their respective chapters, carcinoma of the 
body is distinguished by the combination of neoplasm and degeneration. 
If the cervix is insufficiently dilated and constricts the palpating finger, 
it may be impossible to feel the finer differences of the above tumors. 

Diagnosis of the Extension of Uterine Cancer. 

After the diagnosis of cancer of the uterus has been made there 
arises the question whether it is confined to its original site or has 
already attacked the adjoining organs. The possibility of removing 
the cancerous focus at all, or at least with any prospect of 
permanent cure, depends on the question whether the dis- the Ex"ensio°n 
ease has spread outside of the uterus or not. It is true that °^ clnceT 

such progress has been made in operative technique, and 
the primary results, even of our most radical operations, are now so 
good that we venture to follow the cancer everywhere with the knife, 
stopping only when we reach the bony pelvis. The exact determina- 
tion as to whether the cancer is still confined to the pelvis no longer 
has the same value which it had about ten years ago, when no operation 
was attempted if cancer could be demonstrated anywhere outside of 
the uterus; nevertheless, the operator at least cannot afford to neglect 
this question, because the prognosis of the operation still depends on 
the extent to which he is obliged to carry it, and because the permanent 
result is even more closely dependent upon the extent of the cancer. 
For the family physician the point is not so important, and we advise 
him to let the operator decide this question, on which the life or death 
of the cancer patient depends, particularly as the operative indications 
are still far from being well established, and the necessary methods of 
examination may be beyond the ability of an ordinary doctor. 

The examiner must be familiar with the various lines of extension 
which cancer of the vaginal portion of the cervix and the body (see 
page 337, et seq.) may follow, and be able to trace the course of the 
infection. The cancer may spread within the uterus, or may extend to 
the vagina, bladder, rectum, lymph glands and, by metastasis, to 
internal organs. 

The spread of the cancer within the uterus is of importance 
only to those operators who remove only the cervix in certain forms of 



360 GYNECOLOGICAL DIAGNOSIS 

cancer of the vaginal portion. The examination is made by deter- 
mining, the boundary between the infiltrated and normal tissue by 
bimanual palpation of the supravaginal segment of the cervix; through 
the rectum the thickened or distended portion can be dis- 

Uterus. . . 

tinctly differentiated from the healthy part, which is 
slender and less hard. Extension along the mucous membrane can 
be recognized with the finger or with the sound by the cessation of 
roughness; metastases in the mucous membrane can also be occasionally 
demonstrated with the sound, whereas in the tissue of the uterus it is 
practically impossible to recognize them. 

Involvement of the vagina is readily discovered by palpation. 
Beginning at the vaginal portion the vaginal vault is infiltrated, or the 
surface is rough and nodular up to a distinct boundary line which sepa- 
rates it from the healthy, smooth vaginal wall; superficial 

Vagina. . . , , . . _ _ 

ulcerations are best recognized by inspection. In sub- 
mucous extension of the cancer infiltration and breaking down of the 
diseased portion of the vagina are easily detected by palpation, the 
separation below from healthy mucous membrane being formed by a 
cartilaginous ring. Inspection is often deceptive in this condition 
because the infiltration is covered with normal mucous membrane. 
Metastases in the form of hard movable nodules, ranging in size from 
that of a lentil to that of a walnut, and covered with bluish mucous 
membrane, are found chiefly in the posterior wall. Occasionally they 
appear in the fold surrounding the meatus, where they form subvaginal 
nodes which surround the urethra and after a time ulcerate. 

Extension to the bladder is easily recognized if the vesico-vaginal 
or vesico-cervical septum has been perforated and a fistula has formed. 
It can be inferred in cases of advanced carcinoma with a fair degree of 

certainty, if there is severe vesical catarrh, bloody urine, 

Bladder. .... • i i i i i t • 

or pronounced irritative symptoms in the bladder. It is 
much more important, however, to make as early a diagnosis as possible 
of the vesical disease, partly in order to limit the operation in that 
direction, and partly because it may modify the operative technique 
to be employed. The only reliable method of examining the condition 
of the bladder is cystoscopy, with the aid of which it is possible to 
recognize changes in the bladder wall which are a positive sign that the 
carcinoma is approaching from without. Extension to the wall of the 
bladder occurs in the following manner; Over the spot where the carci- 
noma is approaching the bladder from without, i.e., usually the floor of 
the bladder on the left or right side, next to the trigonuin Lieutaudii, 
the mucous membrane swells and forms thick, parallel folds which 
gradually increase in height, leaving deep depressions between them 
(Fig. 201). The mucosa then becomes edematous, covered with vesi- 



SPECIAL DIAGNOSIS 



361 



cles, the epithelium separates, and a picture similar to that of bullous 
edema is produced. These advanced alterations may be present with- 
out a sign of C3^stitis. Much later small nodules the size of a lentil, or 
flat, elevated areas, appear in the mucous membrane and are easily 
recognized as carcinomatous by their medullary appearance and peculiar 
reflex. The surface of this area is traversed by blood-vessels. If ulcer- 
ation is superadded, the surface of these nodes becomes rough and covered 
with white, more or less firmly adherent shreds of tissue or incrustations 
(Fig. 202); extensive cystitis is usually present at the same time. While 
these changes in the bladder wall do not justify the inference that 
the carcinoma has spread to the tissues outside of the uterus gener- 
ally, the presence of well-marked folds, and particularly of bullous 
edema, are positive signs that the vesicocervical septum is diseased. 




Fig. 201. — Cystoscopic Picture 
OF THE Vesical Mucous Membrane 
WHEN A Carcinoma is in Contact 
with the Viscus. (Modified after 
Zangemeister.) 




Fig. 202. — Cystoscopic Picture 
OF A Cervical Carcinoma that has 
INVADED THE BLADDER. The caiicer 
is covered with incrustations of salt 
and surrounded by bullous edema. 



Ureter. 



With the aid of chromo-cystoscopy, furthermore, it can be deter- 
mined whether the carcinoma involves the ureter. If the latter is 
still intact, its function is not disturbed; but if the stream 
of urine is entirely absent, it may be assumed that the 
ureter is surrounded and compressed by the carcinoma (Hofmeier). 

The diagnosis of involvement of the rectum in uterine carci- 
noma is usually easy if a rectal examination is made. As infection of 
the rectum occurs by continuity from without, the tube 
maintains its full mobility so long as it is not involved; as 
soon as the outer layers of the wall are attacked, the mucous membrane 
becomes immovable; finally nodules form within the mucosa, and by 
breaking down give rise to discharge of blood and putrescent fluid. 

The parametrium is the most important factor in the exten- 
sion of cancer, because changes in the parametrium, more freciuently 
than anything else, limit the possibility of operation. Undoubtedly 



Rectum. 



362 GYNECOLOGICAL DIAGNOSIS 

opinions have undergone a change on this point, and whereas formerly 

no operation was ever performed in a ease of uterine cancer if the 

parametrium was positively known to be diseased, we now regard only 

the most advanced stages of parametritis as counterindi- 

Parametrium. . t i i i • i i t • i n 

catmg radical abdommal hysterectomy. it is thererore 
important, not to decide whether the parametrium is diseased or not, 
but rather to determine whether the disease has advanced to such a 
degree that there is no longer any prospect of a primary, or at least 
of a permanent result, if operation is performed. This question has not 
as yet been answered unanimously, and the many examinations that 
have been made show that the first beginning of carcinomatous disease 
in the parametrial tissue cannot be recognized by clinical methods. 
While we are, therefore, not in a position to say definitely that the para- 
metrium is diseased, we can never be sure that it is healthy. As it is 
the posterior portions of the pelvic connective tissue that are usually 
attacked, combined examination through the vagina is rarely success- 
ful, and a positive opinion with regard to the condition of the para- 
metrium, particularly in the earlier stages of disease, can only be formed 
if the vaginal vault is soft and yielding and the abdominal parietes are 
very thin. The examination should, therefore, be made chiefly through 
the rectum. In order to make an accurate palpation of the portions 
of the pelvic connective tissue situated high up, alongside of the cervix, 
it is usually necessary to introduce the palpating finger beyond the fold 
of Kohlrausch. If the examiner is unable to reach high enough with one 
finger he must employ two, and that is possible only in anesthesia; 
but as it would weaken the patient too much to give her a general 
anesthetic shortly before the major operation, this method must be 
limited to cases that are really doubtful. The examination consists in 
introducing one or two fingers high up into the rectum and at the same 
time placing the thumb in the vagina so as to grasp the parametrium 
from both sides, while the other hand assists in the examination from 
without. In this way, very slight changes in the parametrium can be 
discovered. So long as the parametrium is healthy the fingers can 
easily be brought together immediately alongside of the cervix, and 
the soft connective tissue, the round contour of the healthy cervix, 
and the normal or slightly stretched folds of Douglas can be felt. 
Conversely, however, it is not justifiable to conclude from such find- 
ings that the parametrium is quite intact; for the earliest changes 
demonstrable only with the microscope are, of course, imperceptible 
and cannot be recognized even by the most accurate palpation. 
Freedom from carcinoma as determined clinically does not coincide with 
microscopic integrity of the tissues; if large portions of the carcinoma 
have already advanced beyond the cervix, the adjoining parametrium 
is thickened and forms together with the cervix, a hard nodule of 



SPECIAL DIAGNOSIS 



363 



irregular outline; the roundness of the cervix at this point disappears 
and the outline becomes irregular; thick bands of tissue extend to both 
sides and backward. In a still more advanced stage the nodular bands^ 
as thick as a finger, are felt extending, and closely attached to, the pel- 
vic wall. At the same time the examiner determines with the thumb, 
which is introduced without much force into the carcinomatous cavity 
through the vagina, whether the destructive process extends beyond 
the normal contour of the cervix into the parametrium; or, in other 
words, whether the ulcerated cavity is still confined to the cervix or 
not (Fig. 203). On account of the differences in the contour of the 
cervix and in the consistency of the parametrium on the two sides (Fig. 
204), the diagnosis is easiest in those cases in which the parametrium 
is soft on one side and infiltrated 
on the other. More rarely the 
alterations in the parametrium 
are confined to a few isolated 
thick bands of adhesions passing 
from the folds of Douglas to the 
pelvis, and occasionally inter- 
rupted by a few nodules; these 
bands correspond to carcinoma- 
tous lymph vessels surrounded by 
a zone of inflammatory reaction. 
In cases of ver}' extensive infil- 
tration of the parametrium not 
accompanied by disintegration of 
the tissues toward the vagina, 
extensive tumors of the consist- 
ency of cartilage and with nodular 
surfaces are felt occupying the 

entire space between the uterus and the pelvic wall, particularly the 
posterior portions of the pelvis. It is difficult to decide by palpation 
whether the carcinoma in its advance toward the bladder has gone 
beyond the cervix and invaded the anterior parametrium; but it 
may be surmised if the anterior wall is destroyed and the remaining 
layer, by a simult^neous examination through the bladder with the 
catheter and through the cervix with the finger, is shown to be very 
thin. The earliest beginnings of the extension in this direction are 
recognized with the cystoscope. A much less reliable sign of disease of 
the parametria is fixation of the uterus, i.e., loss of its normal mobility. 
It is true that when the parametrium is absolutely healthy, the uterus 
is quite movable and can easily be drawn down to the vulva; but 
even after that portion of the parametrium which is in contact with the 
cervix has been attacked by carcinoma, while the lateral portion is 




"^C?^ 



Fig. 203. — Advanced Carcinoma of the Cervix 
Involving the Parameteium on Both Sides. P.-F. 
Yi. (Original.) The cervix and the adjoining portions 
of the parametrium on both sides form a large cavity, 
around which the entire connective tissue as far as 
the pelvis is infiltrated. 



364 



GYNECOLOGICAL DL\GNOSIS 



still free, the normal mobility of the uterus is practically preserved; 
fixation does not occur until the infiltration reaches the pelvis, and 
even at that stage errors in regard to the degree of mobility are not 
infrequent. Moreover, inflammatory affections, which are so extraor- 
dinarily common, produce the same fixation of the uterus. The degree 
of mobility is of some value as a measure of the technical difficulties that 
may be expected in a vaginal operation,' but it is worthless as a sign that 
the cancer has spread to the parametrium. The mobility of the uterus 
is investigated by seizing the healthy portion of the portio vaginalis with 
a double tenaculum and having an assistant draw it down while the 
surgeon makes an examination through the rectum and abdominal 

walls, if possible under anesthesia. 



i^:^ 




^c:^ 



The diagnosis of carcinoma- 
tous disease of the parametrium 
sometimes presents great difficul- 
ties. Subserous myomata 
in the peripheral portion of the 
cervix and adjoining parametrium 
may produce the same signs as 
when the carcinoma has invaded 
the pelvic connective tissue at 
this point. Under anesthesia it 
is usually not very difficult to 
distinguish the round contour of 
a myoma from the diffuse outline 
of a carcinoma. The differential 
diagnosis is very difficult when 
the myoma is surrounded by 
exudates. Disease of the 
adnexa very often simulates carcinomatous infiltrations of the para- 
metrium, particularly when the thickened tube or the ovary has dropped 
into Douglas' space and is surrounded by exudates and adhesions to 
the peritoneum in the neighboring folds of Douglas. As a rule the con- 
sistency of these tumors is not so cartilaginous as that of carcinomatous 
infiltration, and the connective tissue and cystic tumors can be referred 
without hesitation to the adnexa. The carcinomatous infiltration is in 
immediate contact with the vaginal vault, and situated in the horizontal 
portion of the parametrium alongside of the cervix; whereas adnexal 
tumors are usually felt somewhat higher up, are not adherent to the 
lateral aspect of the cervix, and contain some soft connective tissue, 
providing the latter is not involved in the inflammation. It is possible 
occasionally to separate adnexal tumors of this kind from their adhe- 
sions, when they may be differentiated from the uterus, and the 



Fig. 204. — Carcinoma of the Cervix and of the 
Entire Left Parametrium. P.-F. }'}. (Original.) 
The carcinoma, originating in the left wall of the 
cervix, has invaded and infiltrated the connective 
tissue as far as the pelvic wall, while the right side 
is completely free. 



SPECIAL DIAGNOSIS 365 

thickened tube traced as far as the cornu. The greatest difficulties are 
encountered in attempting to determine whether a thickening in the para- 
metrium is carcinomatous or inflammatory. Extensive infiltrations or 
tumors in the pelvic connective tissue are usually inflammatory, par- 
ticularly when they have broad attachments to the pelvis or develop in 
regions which are not usually reached by carcinoma, i.e., the recto- 
vaginal septum, and the anterior and lateral portions alongside of the 
bladder. The consistency of inflammatory tumors, instead of being 
cartilaginous, is soft during the early stages, and fibrous and unyield- 
ing in older processes; the shape is usually flat, while carcinoma is 
round or nodular. The thickened bands which represent infiltrated 
lymph vessels, either of a carcinomatous or an inflammatory nature, 
freq'uently both, are difficult to interpret. One of the most reliable 
factors in the diagnosis of infiltration of the connective tissue is the 
continuity of the process with the carcinomatous focus at the cervix; 
if the infiltration is fountl on the side on which the carcinoma has 
locally advanced farthest in the vagina, or if by means of bimanual 
palpation a direct connection between the carcinomatous cervix and 
the thickening in the connective tissue is made out, or if the fingers 
introduced through the ulcerated cavity enter the thickening in the 
connective tissue, there is no doubt about the carcinomatous nature 
of the disease. 

Extension of the carcinoma to the glands and the correspond- 
ing lymphatic region depends to a certain degree on the variety of the 
carcinoma and its local extension. Glandular involvement occurs 
earliest in cervical, and latest in corporeal cancer; while 

. . . . Glands. 

Simple carcinoma or the vaginal portion occupies an inter- 
mediate position. So long as the carcinoma spreads only within the 
uterus, glandular disease is rare; as soon as the first carcinomatous 
foci develop outside of the uterus, glandular diseases become more fre- 
quent, and their frequency increases steadily in proportion as the car- 
cinoma advances in the parametrium. As the earliest carcinomatous 
foci in the parametrium are not recognizable clinically, one must be 
prepared to find glandular involvement even when the parametrium 
feels soft and healthy; it is, therefore, impossible to give exact figures 
with regard to the frequency of glandular involvement. The figures 
obtained thus far range between 20 and 60 per cent. From a diagnostic 
standpoint, it is more important to know that carcinomatous glands 
have been found in 19 per cent, of cases in which the parametria were 
histologically free from cancer, in 22 per cent, of those cases in which 
the parametria were only clinically healthy, and in over 50 per cent, 
of cases of clinically demonstrable carcinoma in the parametria. We 
are not as yet in a position to give a correct general figure. Satisfactory 



366 GYNECOLOGICAL DIAGNOSIS 

palpation of the iliac glands is possible only in profound anesthesia 
by introducing two fingers high up into the rectum and advancing 
toward the sacro-iliac articulation, the abdominal walls being at the 
same time forcibly depressed from the outside at the corresponding 
point; if the glands are distinctly felt they are always enlarged. As a 
rule, they give the impression of tumors the size of a walnut, single or 
in groups, very hard and almost immovable, usually on the side where 
the carcinoma has invaded the parametrium. Very rarely parametrial 
lymph glands are found between the uterus and the pelvic wall in the 
form of movable nodules of hard consistency, ranging in size from that 
of a lentil to that of a pea; palpation of these glands is always very 
uncertain. Examination of the inguinal glands is quite easy; they 
are frequently enlarged, indurated, at first movable and during the later 
stages adherent and, by infection of the neighborhood, produce large 
tumors which break down in the centre and become soft. The skin 
over the glands is adherent and reddened until finally spontaneous 
rupture takes place. The glandular enlargement may be mistaken for 
an inflammatory process, which is so common in this region; but the 
hardness and the fact that the glands remain movable for a compara- 
tively long time are in favor of carcinoma. The lumbar glands 
can be felt only when the intestines are empty and the abdominal walls 
are thin and poor in fat, as immovable hard nodules on the vertebral 
column. Personally, I have never succeeded in feeling them. The 
finding of enlargement or induration of the glands, especially of the 
pelvic glands, is however by no means a proof that the enlargement 
is carcinomatous; for chronic inflammations produce the same changes. 
On the other hand it has often been shown that glands of a normal 
size and consistency may contain the first beginnings of a carci- 
noma. This fact, in connection with the great difficulty of feeling 
the glands at all, materially detracts from any diagnostic and prog- 
nostic importance that may attach to a clinical examination of the 
glands. 

The examination for metastasis is of no importance what- 
ever in uterine cancer, because it does not occur until after the cancer 
has gone beyond the uterus. The earliest stages cannot be diagnos- 
internai tlcatccl, and mctastasls can only be inferred from certain 

Organs. syuiptoms, such as hemoptysis and hematemesis. After 

the metastatic tumors have attained a certain size they can sometimes 
be demonstrated by the methods of examination employed in internal 
medicine. The metastases which occur in the ovary, particularly in 
carcinoma of the body, are more important because they can easily be 
removed by operation; in these cases ovarian tumors with the clinical 
signs of malignancy are found. 



SPECIAL DIAGNOSIS 367 

Diagnosis of Recurrence. 

As the indications for operation are extended more and more in 
the treatment of uterine cancer, the diagnosis of recurrence becomes 
more and more important to the practicing physician, and this phase of 
the subject will therefore be discussed at this place. 

Recurrence in the narrow sense of the term is applied to the 
reappearance of the cancer at a point where it was not demonstrable 
before the operation; in the wider sense, however, the 
term includes also the subsequent growth of the can- 
cerous masses left behind at the operation. I shall adopt the general 
custom and use the term in its wider sense. 

Recurrence may be local, when the cancer reappears at the 
original site or at some point in the wound produced at the operation; 
the cancer may recur in the lymph glands in any part of the entire 
body; or there may be metastatic recurrence, when 

, !• 1 c I 1 1 1 1 Classification. 

the tumor, extendmg by way or the blood paths, appears 
in some internal organ, in the case of uterine cancer most frequently in 
the liver, lungs, kidneys, stomach, bones, ovary, and peritoneum. Clini- 
cally, in view of the difference in the symptomatology, we distinguish a 
closed and an open recurrence. The former develops behind the 
closed vaginal tube in the depths of the true pelvis; the latter leads to the 
formation of an ulcerative cavity communicating with the vagina. 

The symptoms of cancer, which have been described and which 
have some value as suggesting the existence of carcinomatous disease, 
are of still greater importance in the diagnosis of recurrence, because, 
after removal of the uterus, the healthy vagina alone 
rarely gives rise to hemorrhage and discharge. These two 
symptoms occurring after an operation for the removal of cancer, are 
very ominous and are associated with a third very suspicious symptom, 
namely, rheumatoid or sciatic pains in one leg or in one hip, which 
appear particularly when the tumor recurs in the depths of the pelvic 
connective tissue, and later pronounced edema of one lower extremity. 
Grave cachexia, in the absence of bleeding or discharge, should arouse a 
suspicion of metastatic recurrence. All these symptoms are of value as 
suggesting the existence of disease, the diagnosis of which can, of course, 
only be made by an examination. 

Local superficial recurrence in the mucous membrane of the 
vagina is exceedingly rare; it takes the shape of papillomatous or flat 
infiltrations with nodular, friable surfaces, resembling carcinoma of the 
vaginal portion, and trenchantly separated from the healthy Local 

mucous membrane. Granulations in the scar or in the tubes Recurrence. 
that have been sutured into the angles of the wound — with ectropion 
of the mucous membrane, which bleeds at the lightest touch — should 



368 



GYNEC( J I AH i ICA 1 . 1)1 AGNOSIS 




arouse a suspicion of recurrence, Ijut tlie granulations usually feel 
softer to the touch. In such cases the microscope often has to be con- 
sulted. In a few cases I have observe(l a I'are form of recurrence after 
cxtirpul i<tii of (•;i,i'ciii()iii.'i, (if IIh; vagiruil portion, with extension to the 
vaginal vault. The nchuil appearance of the secondaiy tumors in these 
cases was preceded hy diffuse thickening of the mucous menrbrane, 
wliicli presented a papillary and velvety appearance; the affected por- 
tion looked as if it had been flayed, and merged insensibly with the 
healthy mucous meml)rane. This stage, which the microscope showed 
to be still a benign thickening of the epithelium, was in every instance 
f()ll()vve<| in a short time by carcinomatous disease of the affected 

portion. Moi'c; fre(iuently the 
secondary tumor develops in the 
subvaginal tissue, where it pro- 
duces roundish nodules of carti- 
laginous consistency and great 
mol)ility, projecting into the lu- 
men of the vagina, and at first 
covered with mucous mendjrane. 
Tliese nodes very soon I'upture 
into tlie vagina and produce char- 
acteristic carcinomatous cavities 
with infiltrated edges. 

If the tumor recurs in the 
deeper port-ions of the pelvic con- 
nective tissue, the site of predi- 
lection being the anterior parame- 
trium and the base of the broad 
liganusnts, tiie nodes are at a greater distance fi-om tlic^ vaginal canal. 
They are usually felt through the vagina as circumscribed tumors 
of cartilaginous consistency, often loosely connected to the pelvic wall 
(Fig. 205). If there is any susi)icion of recui-i'ence, a rectal exam- 
ination must not- be neglected, because the first beginning of the 
secondary tumoi' in immediate' contact with the pelvic wall can only 
be recognizetl in that way. Nodes of recurring cancel' not, iidVe((ueiitly 
make their appearance in Scluiehardt/s incision. Soinetiiiies extensive 
infiltrations of the entire pelvic tissue are found, which develof) in 
large jjortioiis of th(> ])ai'ametrium (Fig. 20(1), have a cartilaginous 
consistcnc}^, are sometimes nodular, early k^ad to t lii'oiubosis of the 
femoral vein, and cause severe pain and early cachexia. (Circumscribed 
recurrence in tlie parametrium may easily be confounded with inflam- 
matory thickening in adnexa that have been left behind; but the latter 
are usually softei', n,nd partially cystic, and occasionally 1 he tube antl ovary 




Fig. 205. — LofA-i, T! KfonnTONCE in the Bight 

PAUAMKTfllUM, Ai'TlCn ToTAL E.XTIRCATION OF THIO 

Utehus. P.-F. '/i. (Original.) Tlie seconilai-y 
tumor developed from a Hmall germ left beliind near 
the right angle of the wound. 



SPKCIAF, DJA(;\()SIS 



309 



€ati I)c inadc oiil. licciirrcnccs in I Ik- M;ii|i|ci' are recognized will: ihc 
aid of I lie cysiosfopc. 'I'ln' fiiKliiif^s arc di'-cilhi'd on pajijo 301. VV'Iumi a 
second ;ii-y nodule ;i|)) iron cIks tlu; Ijladdcr, 1,1 ic Hiucoii!-; membrane i,s ilirown 




Fi';. 20fi. — RKcxTirtKN'K i\ the IIk;ht PAKAMi/riiirjM, ai'ckii StjpnAVAGiNAj/ Ami'Otat/on of 'nr)-; Ci;nvix 
(Inoculation llecurrence;. V.-F, '/s, (Original. j 

into folds, and bullous edema appears just as in the case of extension of 
a primary cai'cinoma of the cervix to the vesicocervical septum. 

Ghuidular rc'currence appears either in tlie iliiic or in the 
lumbar glands, depending on wliat pari of the uterus is attack<;d, ;ind 




Fir,. 207. — OryANnuj.Aii IIkcubrk.nck aftbd Totaj. ExTrnpAT/ON of thi-; UTicnua, P.-F, 'A, (Original,) 
Glan'iular ina.hw;b at the pelvic wall on each side; to tlie inner >:ide of the glan'J» the two ovaries, 

there produces changes similar to those found in the diseased glands 
with the primary uterine cancer. Recurrent carcinoma in the iliac 
glands can be recognized only by a combined examination through the 
rectum in complete anesthesia (Fig. 207). 

The diagnosis of metastatic recurrence is fraught with the 
same difficulties as that of metastases in general. 

24 



370 GYNECOLOGICAL DL\GNOSIS 

11. Sarcoma of the Uterus. 

Sarcoma is much more rare than carcinoma of the uterus and 
differs from the latter in that the neoplasm occupies the uterine body 
very much more frequently than the cervix. Before discussing the 
diagnosis proper, we shall again describe the 

Clinical Pictures and Lines of Extension. 

Sarcoma of the vaginal portion, beginning in the outer surface of 
the structure, is extremely rare. It takes the same forms as carcinoma, 

most frequently that of the cauli- 
flower tumor, and can therefore be 
identified as sarcoma only with the 
microscope. Even the histologic dif- 
ferences are so slight that there is 
some reason to doubt whether it is 
to be regarded as a separate path- 
ologic entity at all. 

Sarcoma of the cervix appears in 
two different forms: polypoid tu- 
mors with a more or less extensive 
attachment to the wall, of soft con- 
sistency and smooth surface; and a 
racemose sarcoma peculiar to the 
cervix, which grows out of the part 
in a coherent mass and produces in 
the vagina a conglomeration of vesi- 

F:o.20S.-R.cE^xosES.^HCOMAO^THEGEK- clcS and UodulcS of VarioUS sizCS, 

vix (after Pernice). }. The tumor is attached gpi-pading gTaduallv 111 the lumCU of 

to the vaginal portion ; a sound has been passed c o o 

into the cervical canal ; the outer surface is in 1\-^q canal (Fig. 208). TllC sizC of 
places covered with adherent shreds of epithelium. 

the vesicles, or small cysts, and the 
length of the pedicle by which they are attached, vary; sometimes they 
are translucent, at other times dark blue from infiltration with blood. 
Sarcoma of The entire structure closely resembles a hydatid mole. Later 

theCervbc. ^|-^g sarcouia spreads to the parametrium and sometimes 

produces metastases by way of the blood paths. Racemose sarcomata 
are very often mixed tumors composed of mesodermal derivatives. 
Sarcoma of the uterine body begins in the mucous mem- 

Sarcoma of _ • n "" 

the Uterine brauc Or witliiu the uterine wall- 

Body. _, ,. , 1 • 

Sarcoma ot the mucous membrane m rare cases 
has a diffuse origin and causes flat prohferation of a papillary, villous 
character, either in the mucous mendDrane itself or underneath the 
mucosa, causing it to bulge toward the uterine cavity. A more fre- 




SPECIAL DIAGNOSIS 



371 



Mural 
Sarcoma. 



quent form is pol5q)oid sarcoma, which is circumscribed from 
the beginning and produces tumors that fill and in their further growth 
distend the uterine cavity and, after dilating the cervical 

• 1 • mi CI Sarcoma of 

canal, grow into the vagina. The tumors are soft, of lobu- the Mucous 

lated structure, and in the early stages covered with intact 

mucous membrane; later they break down and ulcerate (Fig. 209). 

Mural sarcoma in the majority of cases results from degen- 
eration of a preexisting myoma, and may appear in any one 
of the three forms of that tumor. Much more rarely the 
sarcoma results from degeneration of the constituents of the uterine 
wall, chiefly the blood-vessels ; but the existence of this form as a 
separate variety is still open to question. 

The clinical pictures, which are also 
produced by sarcomatous degeneration of 
myomata, have been described on page 
289. Pure mural sarcomata are usually 
observed as multiple nodules, with the 
remains of uterine muscle in the intervals 
between them. 

At first sarcoma of the mucous mem- 
brane tends to grow toward the cavity of 
the uterus, within which it spreads out 
and thus produces enlargement of the 
uterus; much later it involves the muscle, '^J,, 
which in the meantime has often become 
greatly hypertrophied, and slowly works 
its way through the uterine wall. As it 
continues to grow it breaks through the 
serous covering and leads to the produc- 
tion of nodular tumors alongside of the 
uterus, which become adherent to the intestines and bladder and may 
later perforate into these organs. This tendency to grow toward the 
uterine cavity is to a slight degree observed also in mural 
sarcomata, but their chief line of extension is through the 
muscle itself; sometimes they also reach the abdominal cavity. Sarco- 
mata resulting from the degeneration of myomata in the main retain 
the direction of growth of the myomata. Interstitial tumors ultimately 
also break through the wall and enter the abdominal cavity. 

Metastases occur usually by way of the blood paths and are 
observed in about one-fourth of the cases of advanced mucous sar- 
coma, the sites of predilection are the lungs, intestines, and peritoneum. 
Disease of the lymph glands is more rare. Mural sarcomata much more 
frequently lead to metastases, especially in the lungs, liver, and intestines. 




Fig. 209. — Mucous Membrane Sar- 
coma OF THE Uterine Body (from a speci- 
men in the Kgl. Universitiits-Frauenklinik 
in Berlin). V2. (Original.) The sarcoma 
occupies part of the wall and has produced 
polypoid tumors within the uterine cavity. 



Lines of 
Extension. 



372 



GYNR('()l.()(;i('Al, 1)1 ACNOSIS 



Diagnosis and Differential Diagnosis. 

S;i. I'c () 111 ;i, of llu' \' ;\,,i;'i 11 ;i 1 purlioii is idcnlicaJ with ciii'cu- 

li()iii;i ;iii(l c'lii l)(' (lis! iiit^iiishcd only willi I lie iiiicroscopc. Poly- 

j)()i(l s ;i, re () 111 ;i ( ;i of llic ccrN-ix ;irc rcc()ii,iii/,('(l by I he soil poK'poid 

iii;i:SS('S wliicli ,a:ro\\ into (lie \';iii,iii;i ; lli('\' iii;i,\- he very 
I )iiiK"<''^i>' 'ii"i . . ' . . . ' ' 

DilTnnuiliiil silllil.'U' to 1 1 ly 1 1 1 M.l .'l- if llic sll.'lpc I'Clll.'lillS roiiiid, lull, ill 

I lillKMosis. ' . . I ■ I ' 

lli;it c'lsc I lie coiisislriicy is iniKMi sollcr. I'roiii cm rciiioiiiu 
llicy .■irc (list in^^uislii'd iisii;illy Uy I lie I'lud lli;il iilccrid ion lakes phicci 
iiiii(di lal('c;uid by I heir pronounced leiidency l.o ^row loward iJic cuvity. 

nliltralion of llie base 
fy' /'"I - — -^ « and siirroiindin^ii,' tissue is 

\'ei-\- inuidi rarer in sar- 
coiiia. I lian in earciiionia. 
Iv ac e 111 o s e s a- r - 
(' o ill a. of (lie cervix, 
when full)' de\('lope(l, is 

— ' ;''^Sv^lv>v^'i <'=i^''y I'ccognized by its 
(diara.clerislic a. |) p(>n r- 
ance. I^y palpation and 
inspect ion a. I o ii e I h e 
,ti,ro\\ I h may be inisliiken 
for a hydatid mole a:l)()ut 
to be expelled ; but if the 
l)a.se can be palpated, the 
tumor cau easily be recog- 
nized by the absenci^ of 
a.iiy connection with \\\(\ 
c(>r\ical wall. Signs of 
|)regiia.iic\', especially of 








^A«'^-;y-i 



''■'**i«lliKiilB*''''' ■■•^£3>* 



2i---> 



Fio. IJU). M vuHAucoMA oi' •\'\\v, IT'i'miiNio Bonv (from a sjxm^ 
inioM in Uu- \\^. UiiivorsiliilN-Kriuioiikliiilk in Heriiii). Vi- COi'Ik 
iiml.') 'rh(> Willi (!(iii(,niiiM an intorNlilial myoma whipli, on the side ellla I'gemell t , ai'e loUlul 
iowar'il I luMilerine (*!i\'il \', is (lie seal of (■at'ciin>ni:ilous (K'^xnu'ral ion. , 

111 I he uterus. I he diag- 
nosis is more dillicult if the racemose stage, \vlii(di of course depends 
(Ui the free development of the tumor in the \agiiia, has not yet 
occurreil. 'I'lie mass may be still (|uite coherent, or just beginning to 
l)reak up into indixidiial lobules, and, as it appears in the os, may be 
misiakeii for ;i. mucous p<>l\'p, which sometimes has a. simihir sliap'.\ 
The microscope often has to decide. 

Mucous carcinoma of the utci-ine body is heralded by 
ccM'taiu sympt'Oms \\hi(di, ;is in (he case of caj'cinonui, suggest the devel- 
opment, of such a (iimoi- and denuind a. careful exaniiiuUion. Tlieso 
s)'iiipt(Hiis are irregular liemorrhages, particularly in the menopauso, 
and persistent disidiarge of bloody serum. The di.agnosis is made in 
the saaiie wa\' as (ha.t of cancer of the uterine l)ody. Himanual palpation. 



SPECIAL 1)IA(;N0SIS .'r/;5 

in case the iuinoi' is small, may he ciilircly negative; wlicrcas, if tlio 
tumoi' is lar^c, a, uiiil'oi-m (•iihii'ji.'cmcnl, of the ut-cinis, usually with a soft 
consistency, is discovered. A positive diagnosis of sarcoiiKi is possible 
only by means of microscopic examination of the tissue removed from 
the uterus, or by digital exploration of the cavity. The histologic diag- 
nosis in this case is the moi-e rcdiablc, but is undoubiccUy more didicult 
than in the case of carcinoma, and the results of mici'oscopic examinati(jn 
fre(|uently have to be controlled by exploration. If the cervix is open, 
the lattei' should never be omitted; if the uterus is found to contain 
diffuse tumors of soft consistency, and an irregular, but usually smooth 
surface into which the finger can penetrate, the condition is sarcoma. 
Circumscribed sai'comata freciucuitly cannot be distinguished from 
softened myomata or mucous ])olyps by the sense of touch, and the 
diagnosis must be decided by the microscope. 

The diagnosis of mural sarcoma I'csulting fi-om the degenei'a- 
tion of a myoma has Ijeen described at length on page o71. Mural 
sarcomata not developing on a myomatous foundation are at first mis- 
taken for interstitial myomata because they produce great {enlargement 
of the uterus, and the distinction between the two will depend chiefly 
on hnding the signs of malignant degeneration. 

Fresh diagnostic difficulties arise when the sarcoma breaks through 
the uterine wall producing soft tumors alongside of the body which, 
depending on their size, consistency, and connection with neighboi'ing 
structures, may be mistaken for ovaria,n lumoi's, heinatoma, or exudates. 

III. Chorionepithelioma of the Uterus. 

(Syncytioma mali^^num.) 

Chorionepithelioma originates in the epithelial covering of the 
chorionic villi and unites in itself the two different components of those 
structures, — the cells of Langhans and the syncytium. The tuinor 
therefore presupposes the presence of an ovum within the uterus. 
Pregnancy may have terminated in abortion or gone on to term; but 
in by far the greater nundtcr of cases th(; tumor develoijs on the scjil of a 
previous hydatid mole. As the disease begins not in the ovum itself, 
but in the constituents which have been left behind in the uterine 
mucosa or wall after its expulsion, the; gi'owth of the tumor may begin 
a long time after the termination of prc'gnancy. 

Clinical Pictures and Lines of Extension. 

Chorionepithelioma at hrst leads to i)ro!ifcrations at the site of 
implantation in the form of soft vasculai- tumors infiltratcsd with blood 
and growing into the cavity of the uterus, where they enlarge according 



374 



GYNECOLOGICAL DL\GNOSIS 



to tlic available space and entirely fill the cavity (Fig. 211). Horizontal 
extension in the neighborhood is rare. At the same time the neoplasm 
infiltrates the uterine wall, which breaks down; in rare cases the tumor 
continues its growth outside of the uterus and leads to the production 
of similar neoplasms on the external wall, or in the broad ligament. 
The growth spreads mainly l)y way of the uterine veins, which are 
completclj' filled by the epithelial masses of the tumor, producing 
erosion of the vessel walls. Particles of the tumor are distributed by 
the various anastomoses, with the production of metastatic tumors, 
especially in the vaginal wall. If they reach the vena cava they 
are carried into the branches of the pulmonary arteries and produce 




Fig. 211. — Ciiokionkimthdi.ioma of the Posterior Uterine Wall. (Original.) (Specimen from the Kgl. 
Uiiiversitats-Frauenklinik, in Kouigsberg.) 

metastases in the lungs, which are practically never absent. Next to 
the lungs the favorite seats arc the brain, liver, and spleen. 

Diagnosis and Differential Diagnosis. 

The clinical diagnosis is based on the demonstration of a disinte- 
grated tumor of the uterine wall which owes its origin to a previous 
pregnancy. By examination it is determined that the tumor is com- 
posed of the elements of chorionepithelioma. The clinical signs are 
rarely sufficiently positive to form the sole basis of the diagnosis, 
which nuist be confirmed with the microscope. Quite often there is 
a total absence of clinical symptoms, and the diagnosis rests entirely 
on the microscopic findings. 

As in other forms of malignant disease, the symptoms con- 
sist of irr(>sj;ular luMuorrhages or the discharge of bloody serum. Since 



SPECIAL DIAGNOSIS 375 

they usually follow a pregnancy, they may be misleading, because 
they point to retention of placental tissue or fetal parts. Early occur- 
rence of fetal decomposition, with septic or pyemic fever, is not uncom- 
mon, as chorionepithelioma is very vascular and easily breaks down. 
The signs of increasing decomposition soon give the clinical picture a 
malignant character, which is enhanced by the occurrence of throm- 
bosis in the femoral vein. Hemoptysis and infiltration of the pulmonary 
tissue have a peculiar significance because they' point to pulmonary 
metastases, which are practically pathognomonic. 

The physical signs when the cervix is closed are entirely neg- 
ative or limited to moderate enlargement of the somewhat softened 
uterus, which is also observed regularly in cases of retention of fetal 
parts. The tumors which make their appearance on the outside of the 
uterus during the later stages simulate myomata or malignant tumors. 



*<' 



s 




if 



Fig. 212. — Vaginal Metastasis in Chorionepithelioma of the Uterus. \. (Original.) 

Metastatic growths in the broad ligament are usually mistaken for exu- 
dates, hematoma, or soft ovarian tumors. They may occasionally be 
correctly interpreted if taken in connection with the entire clinical picture. 

If the cervix is dilated, soft tumors are felt in the uterine cavity, 
either with a broad or a polypoid attachment to the uterine wall. The 
surface of the tumor is smooth, lobulated, nodular, and the consistency 
is brittle, spongy, and friable. As the tumors develop after a pregnancy, 
the masses are first regarded as retained placenta, from which they do 
not differ very greatly on naked-eye inspection. Their appearance after 
the placental masses have been completely removed is very suspicious 
of chorionepithelioma. The differential diagnosis from other malig- 
nant neoplasms, especially sarcoma, must be made by the history and 
the microscopic findings. 

Metastases of the original tumor, particularly vaginal tumors 
which are easily accessible to examination, play an important part in 
the diagnosis. They appear in the form of tumors ranging in size from 
that of a lentil to that of an egg, and are usually submucous with a 



376 GYNECOLOGICAL DLIGNOSIS 

bluish reflex, as seen through the mucous membrane (Fig. 212). They 
grow very rapidly, become immovable and, after the covering of mucous 
membrane ruptures, undergo ulceration. Metastases of this kintl may 
develop in the vagina and continue to grow while the primary changes 
in the uterus subside; on the other hand, vaginal tumors, indubitably 
benign in character, maj^ result from metastases of simple chorionic 
villi and be associated with chorionepithelioma of the uterus. Hence 
metastases in the vagina are a positive sign of the transportation of 
chorionic constituents; but, unless there are other signs of uterine 
disease, ,do not indicate the presence of chorionepithelioma in the 
uterus. Aside from the above mentioned symptoms of a previous 
pregnancy, the most important event in the history is the expulsion 
of a hydatid mole. It must be borne in mind that a long period of 
health ma}' intervene between the pregnancy and the appearance of 
the chorionepithelioma. 

Microscopic examination is far more valuable than clinical signs, 
particularly in the earlier stages. As the tumors develop imperceptibly 
from retained fetal parts, and may run their course with the same clin- 
ical symptoms, all fetal parts expelled during or after abortion and 
parturition must be subjected to careful microscopic examination, 
especially if there is a previous histor}- of hydatid mole. Any patient 
who has had a hydatitl mole should be kept under observation 
and, at the appearance of the first sjnnptoms, particularl)' irregular 
hemorrhages, an explorator}- curettage should be performed. 



SPECIAL DIAGNOSIS 



377 



The Neoplasms of the Vagina. 

The benign neoplasms of the vagina are tlie fibromyomata; the 
mahgnant are carcinoma and sarcoma. 

Fibromyomata are composed of muscular and connective tissue in 
various proportions and form approximately round tumors up to about 
the size of an apple. They have a predilection for the anterior wall. 
The diagnosis is based on finding the origin of such a tumor in the 
vaginal wall. The consistency is firm, 
usually hard unless secondary soft- 
ening has occurred. The tumors are 
movable so far as the vaginal wall 
permits and are covered with intact 
mucous membrane ; pedunculated 
tumors may become necrotic. In 
their origin and connection with the 
vaginal wall they resemble vaginal 
cysts, but differ from the latter by 
their firm consistency. Cysts on 
inspection appear bluish through the 
mucous membrane. 

Carcinoma may be primary or 
secondary. 

Primary carcinoma of the ■''''"• ^^^- — fibroma of the anterior vaginal, 

. . Wall, protruding through the vulva. J. 

vagina usually presents itself in the 

form of flat neoplasms involving either a part or the entire wall, 
usually the upper portion of the posterior wall. They are circum- 
scribed, with sharp edges, often somewhat elevated above the level 
of the healthy vaginal wall, and the surface is fissured, Primary 

uneven and often covered with a greasy, grayish exudate. carcmoma. 

Mobility is present only during the early stages, and the tumors soon 
become adherent by extension of the process in the paravaginal con- 
nective tissue. The base and the surrounding tissues are shghtly infil- 
trated. More rarely the tumors are large, attached by a broad base to- 
the vaginal wall and gradually distend the lumen of the vagina. This 
variety is slower to break down and retains its covering of mucous 
membrane for a long time. Occasionally carcinoma merely takes the 
form of subvaginal infiltration completely surrounding the canal like a 
ring. In a few cases I have seen a general superficial carcinomatous 
change involving the entire wall and consisting in warty tubercles,. 




378 GYNECOLOr.irAL T)Ty\GNOSTS 

bleeding !ii, llic lighte.st ioncli, williniil inlill rntion. Tlic Ixxinihiry 
bctwcrii i-lic (•;u-ciii()iiiiit()ii,s poi'tion iiiid ihv hcalihy inuc.ouK mcinbriuie 
i,s usuuUy very distiiud ; in only oik; c'isc (lie mucous membrane of the 
ejitii'o vestibule was ulso roii.^li, uiirvcii n.inl bleeding. 

'I'lic rli:i,rif;<'S produrcil ;i,rc siiiiilnr Id lliose clescrilicd ;il«ivc, nn |i;if!;(! ;5G7, us Ilic iliiUiil 
HUlgO <ir I lie irriirrcncc in I he v;if;iiiii :i,l'lcr cxI irpnlJon nf (lie ulcriis. 

Sec'oiidui'y v ;i,ti,'i n ad c a-rc i ii o ni a I'csulis ivom the extension 
by conlJiiuity of cai'duouiat'ous disea,se of neighboring organs, most 
coininoiily I he cervix, rarely (lie bladder, I'ecluin oi' vulva. Occasion- 
ally il occurs ill the nietasiatic form with ca-i'dnonia of the body 
and of the cervix, nai'ticuUarly in the fold surrounding 

Socondary • _ 

ViwiiiiU the meatus. Not- infrei|ueiitly cai'cinoma, dex'clops on the 

(liiiciiHjrrm. • i 1 1 1 1 ■ i r r 

complelely pi'ola |)se( I vaginal wall, usually in the lorni ol 
a Hal inlilti'alion of the aJ)ove d(>scribed cdiaract-er. 

Owing to the thinness of the vaginal wall the cai'cinoma early 
S|)rea-ds to the surrounding |)aj'a.va.gina-l tissue, with the production of 
fla-t thickenings which slowly advance! towai'd the pelvic wall, while 
the pari nearest the vagina breaks down, liladder a^nd rectum are 
attacked earlier than in cancer of the uterus. 'The glands that become 
cnlafgeil iu vaginal carcinoma, a,re the hypogastric- a.nd, in carcinoma, of 
the lower thii'd, the inguinal glands. 

Diaj^nosis and Differential l)iai>nosis of Vaicinal Carcinoma. Idle 
diagnosis is easy l)eca,use the (dianges develop on the surface. 'Jdie 
inlilt I'alion, either in the form of fhif tumors occupying the vaginal 
wall or of nodules, is easil)' recognized by its cart-ilaginous consistcMicy 
a,nd, if idceration is supera-dde(| , the diagnosis is a-bsolutcly (dear. Some 
dillicult.y is occasionally found in the large tumors that are still covered 
with mucous membrane: their livid appearance and ycdlow, translucent, 
])nnctale aj'eas; the soft, consisleiicy ; and a cei'tain tendency to crumi)le, 
\\ hi<di is recognized most easily by cautiously sounding the lumoi- with 
a pi'obe, — a.ll point to ma,ligna.iicy. Quite often, lioweNcr, microscopic 
e.\a.mina.l.ion of a ))iece of tumor is necessary. 

In the differential diagnosis tertiary forms of syphilis are 
the most imporlanl conditions to consider. 'The diff{>rence between a 
gumma and a. cai'cinoma is that in the former the ulcerative i)rocess 
DiiTornMiiai i!^ iiiore pidmiiieiil, and iiilill rat ion is either absent alto- 

l)uwm,,.iH. nvther or it is diffuse, less hard, and surrounds the ulcer. 

Clummatous ulcers are not- friable; the floor is covered with a grayish, 
greasy c^xudate; and the edges ar(> sinuous. Pei'foratiou into adjoining 
organs with the formation of lisliihi' occurs early. 

'r II be re u I OS is of the x'agimv is rare .and has been obser\'ed only 
in a few cases a.s a.n isohUed focus of infection, 'idie condition produces 
Hat ulcei's, with shar|)ly delined and in some places jagged edges, and 



SPKCIAI. I)IA(;N()SIS :{7!) 

discolored siirlncc ; occ.'ision.'dly ;i. tCw |i(';u'ly (idxTcIc nodules ;ire found 
lie;ii- the nicer. Tlie cliiel dilTerenee IVoni c'l reinoni;i^ is I lie ;d)Senee of 
iidill i;U ion. 'I'lie di;i,ii;nosis ni;iy he cle.'U'ed up l>v lindinj.^ l,id)erciilous foci 
in oilier |i;irls of I li(> body and especinJIy liy iirMM'oscopio exjiniin;d ion. 

The di;i,i^iiosis hefween |iiiiii;i,i'y V!igin;d c;ii'cinoiii;i ;uiil one S(!(;- 
ondiu'y lo cincer of ilie iilcnis is l);i,se(l on flie fiict lliaf in llie foniu^" 
the vai;in;d poi-iion ilself is free, excepf possibly for some idcer;d,i()ii 
from willionl on I lie pari, nearest tlie carrcinoma. 

Sarcoma in adidls produces picliires (|nili' similar to some of I lie 
forms of carcinoma, (see p. ;!77). II m;iy l;i,ke the form of .'i, l,'i,rfi;c 
iuinoi' coN'cred willi mncons membr.'ine, wliicli somelimes 
pi'ofnides Irom llie \iil\;i,; or ol ;i, dillnse, ollcii circiil.'ir 
inlillraiion of iJie eiilire vajLz;ina; vvliih^ circumKci'ilxid liai'd uIchm's with 
firm edges -ilie commonesl foi'in of carcinoma -iU'c not seen in sarcoiiia. 
Sai'(Hniui spreads slowly into the deeper tissiK^s and produces inetustaseH 
ill the luii,ii;s ;iiid in the skin. 

In rhildrcn H.'i.rcdiii.'i, (irc.'iiiiiiiKiJIy !i,|)|)c,'un in llir I'drni (if :i. Iiiiikii' vvilli ii, liidiul liii.MCt 
wliii'li liUcr I'onriM r;i,<^(Mn()H(M^X('r(N4('cn(',(:H |■(^s(Mnl)linJ.; I'MrConioHc (^crviciil ciu'ciiHiiniif (MkI cnlircly 
(illiiifr I, Ik- vd^inH. li'rcHJi nodiih^H jippc^fir conUniiiilly in l-lio lu^if^lihorliood an h roHiilL of inlctr- 
lion (ind .'dso incrciisi; in nhc. J''i,\l.(^n,Mi()ii lu (lie d('(^|) Umhuch lidvdH pliico illU). 

The di;i^'nosis of s<'U'coiii;i in adiills is baseil on i he s;iine findings 
as that of c;i,rciiioina, and the two varieties cannot usuaJly be distin- 
guished clinic;dly. The distinction between sarcoiiui and benign tumors 
(particularly (Ibromyomaia) is based on tin- peculi;i,ril ies <»f the l;i,lter 
as discuss(M[ on p. ;J77. 



380 GYNECOLOGICAL DIAGNOSIS 



Neoplasms and Ulcerations of the Vulva. 

In discussing the diagnosis of the diseases of the vulva it will be 
better, instead of giving a systematic description of all the various 
conditions found on palpation and their characteristic peculiarities, to 
start out.with the important general phenomena and, by analysing them, 
arrive at the differentiation of the individual affections. At a glance 
the physician will recognize certain manifestations of the disease, such 
as a circumscribed tumor or a deep ulcer, and will then have to decide 
by the peculiarities of the ulcer, for example, whether it is tuberculous 
or a broken-down carcinoma. In carrying out this analytical method 
the following classification will be the best guide. 

Diseases of the vulva in the main appear in three different forms. 
L I n f 1 a m m a t o r y changes of the mucous membrane. 
Vulvitis, pruritus, kraurosis, psoriasis vulvae 

2. Circumscribed tumor formation. 

Fibroma, acuminate condyloma, lipoma, sarcoma, car- 
cinoma, elephantiasis, tumors of Bartholin's glands. 

3. Ulcerations. 

Carcinoma, syphilis, tuberculosis, rodent ulcer (cstiomene). 

Although certain diseases, such as carcinoma, appear in both forms, 
and one may result from the other; and although, on the other hand, 
it is difhcult to classify such a disease as elephantiasis either among 
neoplasms or among ulcerations, because it combines both changes, 
I am nevertheless of the opinion that the above classification will prove 
the best guide to the diagnostician in the large and difficult field of 
diseases of the vulva, which appear in such a great variety of forms. 

The changes in the mucous membrane are discussed under the head 
of catarrh, and I shall therefore confine myself in this chapter to the 
diagnosis of tumors and ulcerative processes. 

Tumors of the Vulva. 

Fibromata (Fig. 214) most frequently spring from the labia majora 

and represent round movable tumors of hard consistency, covered with 

skin or mucous membrane. During- the subsecjuent growth 

Fibroma. i- i i i i ■ ■ c i 

the pedicle elongates and the tumor, projecting from the 
vulva, may attain the size of a man's head. By the accumulation of 
fluid within the tissue large tumors often develop a soft, and sometimes 
even a cystic consistency. 



SPECIAL DIAGNOSIS 



381 



Lipomata resemble fibromata in their outward appearance, arc 
also pedunculated, rarely flat and spread out, and develop most fre- 
quentl}' on the labia majora. They are softer than fibromata and 
often exhibit the granular consistenc)^ peculiar to fatty tumors. 

Sarcoma, the most frequent seat of which is also the labia majora, 
represents a tumor which may be exactly like a fibroma and distinguish- 
able from the latter only with the aid of the microscope. If the tumor 
is diffuselj^ continuous with the surrounding tissue, or if 
the investing skin is greatly reddened, tense, and immov- 
able, showing that it also is involved, the tumor is probably a sarcoma. 
Among sarcomata must also be included the melanoma, which may 
spring from any portion of the vulva and often originates in a nsevus. 



Sarcoma. 



yT 









Fig. 214. — Pendulous FiBROiMA of the Left Labium Majus (after Kiistner). 



It is characterized by its dark brown or black color, the rapid glandular 
involvement, and early appearance of general metastases (some cases 
of melanoma must be classified among carcinomata). 
Carcinoma appears in three quite distinct forms. 

1. Cancroid represents a more or less prominent neoplasm, on 
the surface of which papillary proliferation or cornification alternates 
with ulceration and discharging areas; degeneration occurs 
late and rarely extends into the deeper tissues. The 
most frequent seats of cancroid are the inner surface of the labia 
majora and minora, the clitoris and the fossa naviculars. 

2. Infiltrating carcinoma represents a large, hard, often promi- 
nent tumor with extensive, deep infiltration and active degeneration; the 
surrounding skin often shows livid discoloration. This variety extends 
more deeply into the tissues than cancroid and early involves the bones. 



Carcinoma. 



382 



GYNECOLOGICAL DIAGNOSIS 



3. Carcinomatous ulcer develops from the two preceding varie- 
ties by degeneration beginning on the surface. It will be described later. 

The glands are usually involved early, in every case the inguinal. 

The diagnosis of cancroids usually presents no difficulties. 
They are recognized by their prominence, hardness, warty surface 
usually with very little degeneration, and the induration of the inguinal 
glands. Multiplicity is not against cancroid, because several distinct 
foci may develop independently or as a result of contact infection. 
There may be some difficulty in distinguishing between cancroid and 
psoriasis vulvae (leukoplakia), which represents circumscribed, 
whitish, somewhat elevated wheals on the inner surface of the greater 




Fig. 215. — Acuminate Condylomata of the Vulva (after Kiistner). 

and lesser labia. These wheals are very often the starting point of 
cancroid, just as cancer develops on the base of lingual and buccal 
psoriasis, and after the removal of such a cancer fresh cancroids may 
develop from other wheals. As there are many transitional forms, it is 
difficult to say whether a condition is psoriatic or cancroidal; as soon 
as the surface begins to be papillary and the base shows infiltration, 
carcinoma should be suspected. The exact time when carcinomatous 
change begins may often have to be determined by the microscope. 
The diagnosis of the infiltration form is based on the carti- 
laginous consistency, the diffuse character of the surrounding tissue, 
the pain, the tension and livid discoloration of the skin, the appearance 
of small foci and the involvement of the lymph glands. These char- 
acteristics suffice for the differentiation from benign tumors, but the 
diagnosis from sarcoma occasionally requires the aid of the microscope. 



SPECIAL DIAGNOSIS 383 

Acuminate condj'lomata not infrequently occur in large 
conglomerations, especially during pregnancy, and form large, cauli- 
flower tumors occupying the entire vulva and the perineum. The 
epithelium may undergo maceration, with the production Acuminate 

of a purulent discharge, giving the tumors a resemblance condylomata. 
to papillary cancroid. The latter may however be excluded with cer- 
tainty by the soft base, the extremely nodular and irregular surface 
without signs of degeneration, and the isolated papillomata which are 
almost always present in the neighborhood. In doubtful cases the 
microscope must decide. 

Elephantiasis vulvae leads to the production of cutaneous 
thickening on the labia majora and minora and on the clitoris, associ- 
ated with infiltration and soft hypertrophic changes in the subcutaneous 




Fig. 216. — Elephantiasis Vdlv^ (after W. Veit). The tumor springs from the mons Veneris, llie pre- 
puce of the cUtoris, and the right labium minus. 

connective tissue. Similar changes are often present around the anus. 
This new-formation of tissue, which probably depends on stasis in the 
lymph vessels, leads to the production of circumscribed tumors which 
protrude from the vulva and may attain the size of a 

,, 111 11 Elephantiasis. 

man s head, ihey are usually attached by a broad base to 
their point of origin. The surface may be smooth (e. glabra), pre- 
senting merely retractions here and there, or irregular and warty (e. 
papillomatosa) . The skin is often translucent, slightly edematous, 
and as a result of degeneration shallow ulcers or widespread destruc- 
tions may occur on the surface. The consistency is soft. The diag- 
nosis is based on these findings and is usually not difficult. From 
cancroid, with which circumscribed papillomatous elephantiasis has a 
certain resemblance, it is distinguished by the absence of infiltration. 
Tumors of Bartholin's glands, as compared with those described 
so far, have in common their position at the site of Bartholin's gland 



384 



GYNECOLOGICAL DIAGNOSIS 



from which they spring. Exactlj" at the site of the gland, i.e., the 

posterior thirtl of the greater labia a little outside of the hymen, the 

tumor develops from a small point by concentric enlarge- 

Tumors of ^ . . 

Bartholin's mcnt. The outer surface is covered with skin, the inner 

Glands. • i i i c i i i • 

With the mucous membrane or the labia majora; the upper 
portion of the periphery is covered by the labium minus. As the tumor 
increases in size it extends downward under the skin of the perineum. 

The topography is so characteristic that the origin of the tumor is 
recognized at a glance. On the other hand, it may be difficult to determine 
the natiire of the growth. The following diseases must be considered: 

(a) Gonorrheal bartholinitis, with occlusion of the duct, 
leads to retention of pus and the formation of a round, sensitive, 




Fig. 217. — Eleph.\ntiasis Vulv^ (after W. Veit). The tumor is elevated, showing the right labium 
minus fenestrated by the ulcer and forming the inferior point of origin of the tumor. Hypertrophic and hem- 
orrhoidal nodes are seen at the anus. 



completely movable, hard tumor. As soon as the infiltration extends 
to the neighboring tissue and the retention becomes an abscess, the 
tumor increases in size, becomes adherent to its surroundings, and 
the skin over it becomes bright red; the consistency is no longer hard, 
and distinct fluctuation is present. As gonorrhea is the only cause of 
bartholinitis, the other clinical signs of the disease and the finding of 
gonococci in the urethra or cervix will at once clear up the nature of 
the hard retention-tumor. 

(6) Cysts of Bartholin's glands are recognized by the 
distinct fluctuation, the transparent or translucent walls, and the 
absence of inflammatory reaction in the surrounding tissue. 

(c) Carcinoma of Bartholin's gland is extremely rare 
and produces a slowly growing, hard tumor in the characteristic situa- 
tion. Recent neoplasms resemble the hard retention-tumors, while okier 



SPECIAL DIAGNOSIS 



385 



cancers are distinguished from the latter by their nodular surface, firm 
attachment to the underlying tissues, and the tension and livid color of 
the skin. As soon as the growth ulcerates or glandular metastases are 
produced, the diagnosis of malignancy is assured. The duct appears 
to resist the cancerous affection for a long time and is often dilated. 

Sarcoma produces the same physical signs; only one authenticated case is on record. 

Ulcerations of the Vulva. 

Ulcerations result from the breaking down of tissues that have 
a tendency to degenerate. As degeneration is always due to a specific 






Fig. 218. — Abscess of the Right Gland of Bartholin, with Edema in the Upper and Lower Segments 

OF THE Right Labium Majus. 

irritant, some newly formed tissue is always present with the degen- 
erated tissue. The clinical pictures observed in ulceration are deter- 
mined by the intensity of the process of new-formation extending either 
horizontally or vertically into the tissues, and the rapidity and com- 
pleteness of the subsequent degeneration. The character of the ulcera- 
tion can occasionally be determined by finding the specific irritant, 
such as the tubercle bacillus. Microscopic study of the specific tissue 
reaction is a most important diagnostic aid. 

1. Carcinomatous ulcers are characterized chiefly by a marked 
tendency to new-formation, which appears in the form of an infiltration 
at the edges and on the floor of the ulcers, as well as in the deeper tissues. 
The surface is rough, nodular, not ragged; the color is bright red and 

25 



386 GYNECOLOGICAL DL\GNOSIS 

in places grayish from the presence of degenerated tissue. The edge 
of the ulcer is rigid, hard and sharply outlined. Metastatic nodes 
are rarely found in the neighborhood. In old conditions the lymph 
glands are usually involved. 

2. Syphilitic ulcer may develop on the vulva in any of the three 
stages of syphilis. 

The syphilitic primary sore is usually solitary, with a 
greatly infiltrated, cartilaginous, often disc-shaped base. The surface 
is a dirty dark red, and shows some desquamation. The ulcer is sharply 
separated from the surrounding tissue and only occasionally surrounded 
by edema when situated on the labia majora. 

Condylomata lata are flat, slightly infiltrated papules with 
superficially degenerating and desquamating epithelium. They are 
usually found simultaneouslj' on the labia majora, perineum and around 
the anus. In exceptional cases they are very much infiltrated and 
superficially ulcerated as a result of mechanical irritation; or they 
may coalesce to~ form large plaques or patches. To confirm the 
diagnosis the entire body must be examined for syphilis. 

Late forms of sj^philis produce gum mat a and the resulting 
serpiginous ulcers with grayish, ragged floors; they are very rare. 

During the first and second stages the diagnosis presents no 
difficulties; ulcers that result from broken-down gummata during the 
later stages may be mistaken for carcinoma or tuberculosis. In doubt- 
ful cases the therapeutic test should not be employed until after car- 
cinoma has been positively excluded. A positive diagnosis can be made 
with the microscope. The finding of spirochseta pallida appears to 
be a positive diagnostic sign of lues. 

3. The tuberculous ulcer has sharp and sometimes undermined edges; 
it is flat, and cicatrization often occurs on one side only. Small tubercle 
nodules are often found on the floor of the ulcer and in the surrounding 
tissue; there is no marked infiltration. The ulcer may develop any- 
where on the vulva. In connection with glandular ulcers polypoid 
proliferations of the tuberculous mucous membrane occasionally occur. 

Case 28. The inner surface of the. left labium minus is the seat of an ulcer with ragged 
edges and lardaceous, bacony floor; the surrounding mucous membrane is red, infiltrated and 
covered with small ulcers the size of a miUet seed. The floor of the ulcer contains the begin- 
ning of a fistula, which terminates in the anterior surface of the rectima in front of the posterior 
commissure. Microscopic examination of an excised piece of tissue reveals giant cells and 
tubercle bacilli. 

The term lupus vulvae is limited to that form of tuberculosis of the vulva wliich 
consists in multiple nodules and, by breaking down of tlie nodules, leads to the formation of 
ulcers and extensive cicatrization. 

The diagnosis of tuberculous ulcer is simplified by the fact that 
it is practically never primary and represents a secondary localization 



SPECIAL DIAGNOSIS 387 

in genital or pulmonary tuberculosis. A search for other foci must 
therefore be made. All doubt may be removed by excising the base of 
the ulcer and finding tuberculous tissue and bacilli. 

4. Rodent ulcer (ulcus rodens, s. chronicum, s. elcphantiasticum) 
is an ulceration accompanying hypertrophic conditions of the skin. 
The ulcer spreads along the surface and, by involving deeper portions 
of the tissue, produces perforations and fistula in the urethra, labia 
and perineum. 

The pathologic status of these ulcerations is still in doubt, as the tissue merely shows 
inflammatory changes without specific elements of any kind in uncomplicated cases. Its 
specific nature must be denied. There is a certain connection with syphilis inasmuch as 
old lues predisposes to the condition. Tuberculosis apparently develops secondarily in the 
ulcers at times. The true cause is usually found in stasis of the lymph circulation (after 
extirpation or suppuration of the inguinal glands), and injuries of various kinds acting upon 
the ill-nourished tissue. 

Well-developed ulcers have a very characteristic appearance. 
They are found in the fossa navicularis, on the lesser labia and clitoris, 
and usually represent flat ulcerations with sharp, eroded, often deeply 
undermined edges. If they extend downward, perforations of the lesser 
labia and deep cavities in the perineum are produced, from which 
fistulse are given .off that go still deeper, often as far as the rectum. 
The ulcers are bright red in color, smooth and shining, and in some places 
covered with exudate; they often have a pronounced serpiginous char- 
acter. While one edge heals by cicatrization, the ulceration advances 
on the other side. The ulcer is accordingly surrounded by radiating 
scars, which may produce ectropion of the urethra and vulva. . The 
tissues immediately surrounding the ulceration are rigid, but there is 
rarely any brawny infiltration. These ulcerations are frequently asso- 
ciated with forms of elephantiasis as described on page 383, and the 
combination of neoplasm and degeneration may produce a very 
complicated clinical picture. 

The anal skin takes part in the process with the production of 
hypertrophic folds surrounding the orifice, and shallow ulcerations. 
Cicatricial strictures and ulcerations are found in the rectum. 

In view of the above findings the diagnosis of rodent ulcer is in 
the main easy. Carcinomatous ulcer is distinguished chiefly by the hard 
infiltration of its edges and floor and of the surroundings parts. Tuber- 
culous ulceration may produce signs so similar that the true nature of 
the process can be recognized only with the microscope by demon- 
strating the bacilli. With regard to the distinction from syphilitic pro- 
cesses, we should adopt the standpoint that rodent ulcer is prone to 
develop on the foundation of syphilitic tissue-predisposition, but does 
not itself represent a syphilitic tissue disease. 



388 GYNECOLOGICAL DIAGNOSIS 



Microscopic Diagnosis of Malignant Diseases of 
the Uterus, Vagina and Vulva. 

In accordance with the meaning of the word ' malignant ' the micro- 
scopic diagnosis of malignant diseases of the uterus includes all those 
affections which do not subside spontaneously, which continue to 
spread without limit, and for the removal of which special 
of Early mcdlcal procedures are necessary. The success of medical 

lagnosis. interference depends on early removal of the malignant 

focus. If it has existed long, or an expectant policy is pursued, radical 
removal, which is always to be aimed at, may be impossible. The indi- 
cation for intervention at the earliest possible moment depends on an 
early diagnosis. As a number of malignant diseases cannot at first 
be recognized clinically, and many benign changes in the beginning 
sometimes appear clinically to be malignant, the microscope must 
decide the diagnosis in such cases. The nature of the tissue seen in the 
microscopic specimen shows whether the alteration is inflammatory 
or malignant. If there is any doubt whether the degeneration is malig- 
nant or benign, a piece should be excised, or the uterus curetted for 
the purpose of microscopic examination, as the latter will determine 
whether a malignant or a non-malignant disease is present. 



General Portion. 

The number of diseases which require microscopic examination to 
determine malignancy are not many. They include first of all carci- 
noma, and with it adenocarcinoma and malignant adenoma, sarcoma, 
and endothelioma; and finally malignant syncytioma and chorion- 
epithelioma. Malignant diseases are recognized by certain changes 
and proliferations of cellular constituents. A number of malignant 
changes, such as tuberculosis and actinomycosis, are definitely identified 
by the presence of the causal microorganisms. 

To begin with, the microscopic diagnosis of carcinoma — 
DiagnosiTor'^"' the carly recognition of malignant tissue — is based solely 
Based on «le ^^'^ alouc ou thc architccturab plcturc — the histologic struc- 
fhe TumoT^ °^ turc. Carcinoma is a malignant neoplasm of very definite 

histologic composition, and a very small particle of the 
tumor often suffices for a positive microscopic diagnosis. We must 
take into account the spurious pictures (artefacts) which make trouble 



SPECIAL DIAGNOSIS 389 

for the inexperienced and which will be described in detail, and 
also the situation from which the pieces to be examined have been 
obtained. As there are physiologic prototypes for the cellular struc- 
tures of malignant tumors (for example, the decidual cell ^, . , • r. 

" ^ '■ ' Physiologic Pro- 

is the physiologic prototype of the sarcoma cell), so there totypes of Maiig- 

. 1-1 11 nant Neoplasms. 

are physiologic or benign types ot tissue which resemble 
the structure of malignant neoplasms. The neoplasms differ in their 
appearance according to the place from which they are derived. The 
erroneous opinions prevailing in regard to so-called 'diagnoses based 
on small pieces' must be attributed either to want of skill on the part 
of the examiner, or the failure to distinguish between the significance 
of definition and that of the structural picture. The definition 
of carcinoma takes account of its origin, emphasizes the ^ ^ . . 

^ _ _ Definition and 

local destruction, the atypical mode of spreading (infec- structural 

T • \ • • • 1 Picture. 

tion of the surrounding tissues), its extension m the more 
remote tissues, the formation of metastases, and the destruction of the 
individual by cachexia. In addition, it includes a description of recur- 
rence, of the etiology, and of the histologic composition. In the defini- 
tion of cancer the entire life history of the malignant neoplasm is 
sketched. In the study of the microscopic picture, on the other hand, 
we have to deal solely with the earhest stage of the disease; there is no 
question of metastases and of extension to the neighborhood. The 
structural picture of carcinoma does not in the least depend on whether 
or not the tumor has broken through its boundaries; cancer is not 
recognized either by muscle tissue or by liver cells. If the specimen 
contains liver cells, all that can be concluded is that the cancer is a 
liver cancer. We recognize cancer by its structure, and our experience 
tells us that the neoplasm is at first local, and later gradually destroys 
the individual's life. The importance of the architecture must be 
especially emphasized. The pathologist who is familiar with the archi- 
tecture is able to diagnose cancer, while he who has only mastered the 
definition of cancer is not thereby enabled to recognize anything. Recog- 
nition of the cancer leads to the microscopic diagnosis, and after the 
diagnosis has been made, it is possible to give a definition; but 
the definition itself has its limitations (for example, in regard to 
heterotopia), just as the architecture by itself may be deceptive. 

According to the definition, cancer is a malignant, epithelial neoplasm of atypical 
growth which, wliile primarily local, spreads by excessive, unlimited proliferation, causes local 
destruction, oversteps the tissue boundaries (heteroplasia), slowly spreads to adjoining, and 
later to more remote parts, either directly or by way of the vessels (lymphatics, blood-vessels), 
and produces metastases in distant portions of the body (heteroplasia). 
The latter, depending on the vital importance of the regions in which Uehmtion of 

11-111 -11 r-ii- Carcinoma. 

they develop, either slowly or rapidly produce a functional disturb- 
ance, and finally the cancerous infection brings about the death of the individual 
from exhaustion (cancerous cachexia). The epithelium is derived from the epi- 



390 GYNECOLOGICAL DIAGNOSIS 

thelium originally present at the site of the cancer. With regard to the etiology, all that is 
known is that traumatism may produce carcinoma, and that there are certain seats of pre- 
dilection indicating a 'weakness' in the composition of the predisposed region; the inference 
that cancer occasionally develops in such localities cannot always be demonstrated or recog- 
nized. Heredity plays an insignificant part. The character of the epithelium at the various 
periods of life (in connection with the character of the body-tissues in the immediate and 
more remote neighborhood) is of great importance even if it cannot be directly seen, stained 

or represented. The bacterial origin of cancer has as yet never been dem- 
Carcinoma onstrated. The theory that carcinoma is an infectious disease, either 

according to the older view of dyscrasia, or according to the more modern 
conception of a disease caused by specific microorganisms, has never been proved. Two 
things, however, are absolutely certain: First, that cellular proliferations and neo- 
plasms develop without the action of any causal microorganisms; and second, that there 
are infectious tumors in the causation of which bacteria play an important part. If an agent 
of which we know nothing should ever be demonstrated, and not merely assumed as the cause 
of cancer, it would not alter the fact that the diagnosis rests on the structure; although it is 
possible that some therapeutic advantage might be derived from such a discovery. 

It is important to remember, for other reasons as well as for the 
value of a diagnosis based on small pieces of tissue, that the definition 
starts out with the assumption of a primarily local origin; this assump- 
tion at once disposes of the objection which has been made 

Cancer is 

Primarily repeatedly that extension of the cancer to the surrounding 

Circumscribed. . ... . . _ . 

tissue cannot be seen m the microscopic specimen, it is 
quite true that we cannot see this extension of the cancer; we only 
infer that it takes place from what we see in the tissues surrounding 
the malignant proliferation, or we may say that we know by previous 
experience that the cancer will continue to grow. There are cancers 
that have not advanced beyond the boundaries of the mucous mem- 
brane; for example, there are polypoid proliferations in which only 
cancerous degeneration is demonstrable, and which are separated from 
the organ by layers of normal tissue; in such cases the carcinoma can 
be radically removed by simple erasion. The important thing is to 

recognize the cancer early, and this in turn depends on 
Cardnomar° thc ability to recogiiize the architecture. The latter may 
ki'^Part or whoUy ^^ summcd up briefly as follows: newly formed alveolar 
E "it hetlai'' Cells spaces not previously present in the tissue and filled or 

lined with an epithelial mass (alveolar or glandular carci- 
noma). The tissue, the normal composition of which is known, is in- 
vaded by masses of epithelial elements, which may be large or small, 
broad or narrow. This leads to the production of vacuoles, clefts, 
tubular canals, which again communicate with one another and are 
completely, or almost completely filled with epithelial masses. The 
epithelial masses grow into the tissue and produce alveolar spaces, and 
at the same time fill them up. 

If the proliferation of the carcinomatous masses is to be compared to the wood-worm, 
or burrowing worm, which burrows and forms canals in wood and destroys it, it must be 
added in the case of carcinoma that the destruction takes place not only at the extremity 



SPECIAL DIAGNOSIS 



391 



occupied by the worm, but the entire system of canals occupied by the proliferating epithe- 
lial masses is the seat of proliferation. At any point of the alveolar spaces which are filled 
with the epithelial masses a fresh burrow may originate and extend into the neighboring 
tissue, — an atypical, resistless creeping onward. In the schematic picture below the arrows 
indicate this slow advance, and at the same time the proliferation that takes place at every 
point (Fig. 219). The more recent stages are usually the narrowest, while the beginning 
proliferations — the oldest stages — are the broadest. There is a difference between the trans- 
verse and tlie longitudinal section; in the latter the communicating, canal-hke passages are 
seen, while in the transverse section the epithelial strands produce circular or oval, flattened 
pictures of different sizes. It should be emphasized that the tissue which the carcinoma invades 
as a destructive neoplasm, at the same time constantly producing fresh carcinomatous tissue, 
is quite different from the neoplastic, destroying epithelial masses. The tissue may be in a 
state of great irritation and become the seat of small-ceUed infiltration; the deeply stained, 
small round cells may, like the decidual cells in decidual endometritis, cover up the epithelial 
masses, particularly if the latter still represent slender, almost fibrous columns of cells (epi- 
theUal cords, carcinomatous nodes). The greater the tenuity of the invading epithelial masses, 
the more easily will the picture of epithelial infiltration — of cellular flooding — be produced. In 





Fig. 219. — Illustrating the Method by Which the Carcinoma Spreads to the Surrounding Tissue. 

(Original.) 



superficially beginning carcinomata the small-celled infiltration may produce the picture of 
a reaction zone or productive zone toward the sound tissue; or the tissue may show no signs 
whatever of the invasion; the cancer nests of solid epithelial cords are simply embedded in an 
apparently intact tissue. Imagine the epithelial masses removed, wipe them out with a brush 
artificially in a microscopic preparation or remove them by maceration, and you will see in the 
tissue the vacuoles, the longitudinal and transverse sections and the system of canals, — in short, 
the alveolar structure into which the tissue has been converted by the epithelial masses. 
Carcinomatous proliferations beginning on the siu-face (derived from surface epithelium) 
may retain their connection with the latter (Fig. 220). Often the superficial layer is destroyed 
or desquamates. Shortly before the appearance of the carcinoma all but the lowest layer of 
cells, which is difficult to recognize, not infrequently scales off from the stratified epithelium 
like varnish. If a typical reaction zone develops between the epithelium, which is apparently 
desquamating (Fig. 221) and in process of disintegration, and the beginning carcinoma, there 
is apparently nothing to show that the carcinoma originates in the epithelium. The carci- 
noma, beginning in small delicate epithelial cords, extends downward to the tissues. At 
first this can be demonstrated only with the microscope, but later the whitish or whitish- 
yeliow epithelial cords can be seen with the naked eye. The large cellular masses are recog- 
nized on the cut surface with the naked eye, and can be expressed like comedones. Although 
a microscope with a magnification of three and a half to ten diameters is necessary for purposes 
of confirmation, the eye should nevertheless be trained to make the diagnosis without any 
magnification, or at least with the aid only of a very low power lens. 



392 GYNECOLOGICAL DL\GNOSIS 

The carcinomatous elements are epithelial in origin and in 
character. It requires some practice to recognize them as such. In 
the large cancer nests and in situations where the growth is slow the 
^ . , ,. , individual elements can often be distinguished by their 

Epithelial '^ ■; 

Origin of contour, particularly in the case of older elements situated 

Cancer. n i i 

near the centre; while younger cells tend to undergo 
peripheral extension. Within the zone of proliferation it is difhcult 
and often impossible to recognize the elements directly, because they 
are so small and delicate that their contours apparently fuse with one 
another. Strands of cancer tissue are also encountered that are filled 
solid with epithehal masses and in which no cell contours at all are 
visible; the round, and often quite uniform nuclei are packed closely 







Fig. 220. — The Carcinoma Originates in the Already Existing Stratified Squamous Epithelium 
AND Sends down Plugs into the Deeper Layers. (Original.) 

together; the cellular material is rolled into a ball and compressed 
so that it appears like a mass of cells without any individual units. 
The cellular material — the cancer nests or cancer cords — is sharply 
separated from the tissue, and sometimes by its stain even 
sharpiVsepa- from the stroma. If the tissue is the seat of small-celled 
roun'ding'Tis"ue. infiltration, the stroma is darker than the epithehal cords; 
and conversely, if the stroma or supportive tissue contains 
but little small-celled infiltration, the stroma is paler. The boundaries 
between epithelial proliferation and stroma are always sharply defined, 
even when, owing to marked epithelial proliferations with many nuclei 
and small-celled infiltrations in the tissue, the line of division between 
the two tissues is difficult to see. 

Carcinoma is an epithelial, malignant neoplasm, with no 
tendency to spontaneous recovery, an atypical and unlimited growth of 



SPECIAL DIAGNOSIS 



393 



distinct alveolar structure, the alveolar spaces being filled with epithelial 
masses. The epithehura is derived from the previously existing epithe- 
lium (portio vaginahs), or from cylindrical epithelium (cervix, body). 





In carcinoma originating in squamous epithelium the original epithelium either 
remains unaltered and forms the starting-point of the malignant neoplasm, or it undergoes a 
change previous to and along with the beginning of malignant proliferation; in that case the epi- 
thelial neoplasm begins in altered epithelium. Stratified squamous epithelium may become 
cylindrical, and conversely, cylindrical epithelium may become stratified; hence carcinomatous 
epithelial cords appear in a great variety of different forms, from thick solid epithelial plugs 
to proliferations covered with a single layer of cylindrical epithelium. The same cancer node 
may contain various modifications — 
metaplasiae, transitional forms between 
squamous and cylindrical epithelium, 
and vice versa. The originally sepa- 
rated ep)ithelial cords, after prolifera- 
ting for a short time independently, 
may fuse and form large conglomera- 
tions. Secondary degeneration the 
result of breakdown or mucous change 
may occm\ 

The architect \i re of the 
carcinoma varies according to the seat 
of its origin. The latter may often be 
determined by the nature of the struc- 
ture; thus a certain composition 
observed in carcinomatous masses ob- 
tained by curettage — metastases, for 
example — may be so characteristic 
that the presence of carcinoma of the 
ovary may be inferred. 

The polymorphous nature of a 
malignant adenoma for a long time, and 
even at the present day, prevented its 
being recognized even by good authori- 
ties as a carcinoma of peculiar structure. 

The carcinomatous proliferations 
beginning in stratified squamous epithelium give rise to the production of thin, narrow cell 
cords (Figs. 220 and 222). The cells may be so closely packed that the contours disappear 
or become very indistinct; or, as in the case of large cancer nests, the peripheral elements 
which are most concerned in the proliferative process may be difficult 
to identify in the preparation; while at the centre, where the process 
is older, large cells with distinct outlines are seen. Sometimes the closely 
packed cells loosen up and appear like desquamated cells. In the micro- 
scopic picture the central portions appear softened, and in the stained 
specimen the nuclei are irregular in size and intensely stained, while in the peripheral 
layers they are fairly uniform. This simple process of loosening in the central portions 
must be distinguished from direct degeneration, in which the cells break down, the 
nuclei become paler, and the chromatin disappears. In the interior of cancerous alveoli 
of this kind a mucoid, fatty or finely granular mass is seen. A peculiar 
necrosis of the cells may also take place at the centre. The cells in that 
case, instead of as usual losing their staining properties, appear to be rolled 
up in a ball and in exceptional cases stain intensely, forming either a dark 
red or a violet mass in the centre, depending on the stain that is used (Fig. 223). The solid 
epithelial plugs which originate in the squamous epithelium, develop a glandular character as 




Fig. 221. — The Sqtjamods Epithelium of the Va- 
ginal Portion scales off like varnish. The cancer plugs 
begin at some distance from the squamous epithelium with- 
out any apparent connection with it. (Original.) 



Carcinoma 

Beginning in 

Stratified 

Squamous 

Epithelium. 



Central Soften- 
ing in Solid 
Cancer Plugs. 



394 



GYNECOLOGICAL DIAGNOSIS 



the result of this central degeneration. Cancers derived from stratified squamous epithelium 
also produce pictures similar to those seen in cancroid of the skin: epithelial pearly bodies 
are arranged in layers like the skins of an onion (Fig. 224); but changes of this kind are 
not very common in carcinoma of the vaginal portion, though relatively frequent in the body 
(see p. 397). The cancer cords are usually round or oval and flattened, sharp pointed or 

indented edges being found as a rule only when the carcinoma spreads along 
Formation. *^® lymph clefts, a mode of extension to which, in contradistinction to the 

others, the term "worm-eaten" is applied. This form of extension is often 
directly continuous as solid cell-cords, the endothelium of the lymph vessels being often 
preserved (Fig. 225). These simple epithehal masses which extend slowly in the lymph- 
clefts must be distinguished from the changes which begin directly in the endothelial hning 



■ 'ti^^; 





WW 

















Fig. 222. — Solid Cancer Plugs of various shapes: 
1. Simple; 2. With beginning processes; 3. A cancer node 
separated from the stroma by 'maceration'; the 'alveolar' 
space is especially well shown. (Original.) 



Fig. 223. — Cancer Plug suggesting 
a gland, with a central lumen contain- 
ing a necrotic mass (secondarily gland- 
ular). (Original). 



of the lymphatics (endothelioma verum). The carcinomata that spread in the lymph 
channels are solid, but may become hollow, developing a loose structure in the central portion. 
With regard to the shape of carcinomata beginning in cylindrical epithelium, 
we must distinguish (1) the behavior of the cervical epithelium and (2) that of the corporeal. 
1. As a rule, the single layer of cylindrical epithelium of the cervix is converted into 
stratified epithelium. At the same time the original inequalities of the cervical mucous 
membrane are smoothed out. The epithelial masses appear uniform in composition, both at 
_ . the surface and in the deeper layers, without distinct cellular outlines. These 

Conversion '■ '' ' 

into Stratified masses give off thick, solid plugs that penetrate into the deeper layers (Fig. 
Epithelium: (a) 226); the epithelial cords are often large enough to be seen with the unaided 
eye and represent gigantic, somewhat shapeless round or cord-like structures, 
1 mm. broad and several millimetres long; rarely they contain a few cervical mucous glands. 
Along with the alteration in the surface epithelium a malignant proliferation begins, as it 
T/ere, in the nascent state. In the place of solid epithelial cords, or along with such cords, 
large epithelial structures with a central cavity, which occupies the structure uniformly, 
are seen, giving the plugs the appearance of a glandular structure (Fig. 227). The conversion 



SPECIAL DIAGNOSIS 



395 



of the cylindrical epithebum in the cervical glands progresses uniformly and jxiri passu with 
a considerable peripheral multiplication; but no solid plugs or cords are produced. In addi- 
tion to the seprimarily glandular forms in wliich the stratification of the cj'lindrical epi- 
thelium does not produce solid plugs, the picture of the glandular form may 
develop secondarity by degeneration of the central masses (Fig. 223). This Glanclurar'Fomf 
central necrotic mass may take the stain so intensely that the nodes are 
distinctly seen in the epithelial plugs, which are visible to the unaided eye. As the central 
metamorphosis increases, the central lumen may become larger, while the stratified parietal 
layer continues to proliferate and maintains a fairly uniform tliickness. This results in 
central breakdown and peripheral boundless proliferation. Mjrxomatous changes may also 










%? 




Fig. 224. — Cancerocs Pldg, 
containing several epithelial pearly 
bodies (onions). Cancroidal form 
of cancer. (Original.) 



Fig. 225. — A Soltd Alveolar Cancer. Di- 
rectly continuous with the further proliferation 
of the growth in the lymph-clefts (carci- 
noma lymphoides). (Original.) 



take place in the large cancerous epithelial cords. The lumina are filled with mucoid masses, 
with here and there fatty granule ceUs, and the stroma is reduced to a few scanty layers of 
cells (Fig. 228). This produces the appearance of confluent, somewhat irreg- 
ular ovula Nabothi; the earher stages of cellular proliferation in the q\ a'^\ y^^ 
form of slowly advancing solid epithehal cords which have become larger and 
exhibit mucoid degeneration at the centre, are also present. Partial 'recovery' takes place 
in these cases along with the slow advance of the most recent stages. 

In contrast to these epithelial, not to say gigantic proliferations, there should be men- 
tioned the rare forms in wliich the entire tissue of the cervix looks as if it had been eaten 
through, and the microscopic section to the unaided eye shows practically nothing at all. 
The tissue is filled with gland-like formations, separated by uniform intervals, but neverthe- 
less interdigitating, and becoming invaginated or evaginated, ■nnthdrawing and then again 
approaching one another without actual contact. Under low power the tissue appears to be 
filled with strands of glandular tissue of fairly vmifonn width, while the individual strands 
are separated by a uniformly wide stroma. Under higher power it is distinctly seen that 



{ 



396 



GYNECOLOGICAL DIAGNOSIS 



the single layer of cylindrical epithelium has been replaced by a uniform stratification of 

one to three rows (Fig. 229). In other cases the cylindrical structure is preserved 

(stratified cylindrical epithelium). This alteration represents the carcinoma which is 

designated malignant adenoma of the cervix (Fig. 230). 

Irre ular Whereas the changes that res\ilt from carcinomatous metamorphosis in 

Cancerous the cervical epithelium and other epithelial structures are uniform — in so far 

Metamorphosis ^g proliferation repeats itself uniformly in the structures — an irregular 
of Glands. , ., , . , • ,i , , t . „ , , , , 

architecture is also occasionally observed. Large portions of the glandular 

structures undergo carcinomatous degeneration; the lumen of the gland becomes greatly dilated 

and lined with stratified epithelial masses, which do not, however, extend over the entire 

gland; part of the latter is preserved (Fig. 231) and seems to form an appendix to the strati- 





fied carcinomatous 
tions above. Tlie epitheliur 
its cervical character, and in this ^vay 
the picture of adenoid or glandular 
cervical carcinoma is produced. Similar 
pictures are encountered in tlie healing 
of erosions and in epidermidalizatiou. 
In this form of carcinoma the gland is 
found but little altered on one side, 
while at the other pole the carcinoma 
continues to advance. Tlie carcino- 
matous degeneration may begin in the 
surface epithelium or in deeper layers 
of the mucous membrane, and the pic- 
tures vary accordingly. 

2. With regard to the shape of 
carcinomata beginning in the c y 1 - 
indrical epithelium of the 
body, in the previously existing sur- 
face epithelium, or in the uterine glands, 
it must be emphasized that the carci- 
noma usually begins in the surface, as 

in the case of cervical cancer, but may also originate in the deeper tissues underneath an 
intact mucous membrane. The cylindrical epithelium of the body may be converted into 
a thick, stratified layer, as already described in connection with the cervix 
(Fig. 226). It gives off thick epithelial plugs which penetrate into the deeper 
layers; the uterine glands disappear, or rarely may be preserved (carci- 
noma alveolare) alongside of the thick cellular plugs, which now 
continue their resistless advance. The entire surface of the uterus may 
be covered with thick, epithelial layers of this kind and, owing to the shallow depressions 
of the surface which correspond to the uterine glands, it may macroscopically resemble 

the surface of the decidua vera with its dilated gland lumina. In 
Conversion ,,,. .,.i ,. f ^ , i-^i 

into Stratified contrast to the delicate, pinkish surface of the normal uterus covered with 

Epithelium cylindrical epithelium, the surface becomes somewhat rigid from the 

cmg-cancer . presence of the thick, epithelial masses; the color is whitish, resem- 
bling icing on a cake, or the surface of a frozen pond. This icing, to adopt a descrip- 
tive term, may cover the entire surface, or it may be limited to the lower portion near the 



Fig. 226. — The Cylindrical Epithelium 
which has been converted into stratified epi- 
thelium grows into the deeper tissues in the 
form of solid cancer plugs. (Original.) 



2. Carcinoma 
Beginning in 
the Cylindrical 
Epithelium of 
the Body. 



SPECIAL DIAGNOSIS 



397 



internal os. Occasionally isolated psoriatic patches are seen. The stratified epitheliuna often 
peels off and is elevated from its foundation in the form of a tongue (Fig. 232). It may be 
compared to a stream of lava flowing over the surface and apparently only covering the 
uterine glands. One gets the impression that the epithelial masses have overflowed from a 
more deeply situated cervical carcinoma (corporeal and cervical carcinomata are often found 
in combination) (carcinoma with icing-like changes of the surface epithelium). 

In addition to this conversion of 
the cylindrical epithelium into a strati- 





FiG. 227. — Cancer Plug of Primarily Glan- 
dular Structure. (Original.) 



Fig. 228. — Carcinoma in a State op Partial Myxoma- 
tous (Mucoid) Degeneration. (Original.) 



fied epithelial mass, formations are observed which in every respect resemble cancroid of 
the skin. Everjrwhere an abundant, onion-like proliferation (cancroid) is seen. This form 
may occasionally grow with tremendous rapidity, and the cancroid pearly bodies (liorny 
cancer) may be found in the smallest, thinnest epithelial proliferations in the deepest portions 
of the tissue (Fig. 233). 

In addition to this conversion into a firm, massive, stratified epithelial layer, there may 
be observed a metamorphosis of the surface or of the parietal epithelium going on hand in 










Fig. 229. — The Cylindrical Epi- 
thelium IS Converted into Strati- 
fied Epithelium consisting of two or 
three rows of cells, and remains every- 
where uniform. (Original.) 




Fig. 230. — The Cylindrical Epi- 
thelium IS Converted into Strati- 
fied Epithelium, consisting of two or 
three rows, and in the main retains its 
cylindrical shape. (Original.) 



hand with a more marked peripheral (centrifugal) growth; these proliferating masses do not 
fill the lumen, but remain parietal and thus produce a glandular structure. The individual 
elements in cancer of the body may (1) retain their more delicate appearance, as compared 
with the cells seen in cancer of the vaginal portion and of the cervix; the protoplasm is finely 
granular and stains faintly. Or (2) the parietal proliferation may be much more irregular 
and less uniform; along with slight or absent stratification there may be found papillary 
accumulations of cells which may project far into the dilated lumen of the gland and finally 
unite with similar outgrowths from the other side. In this way constrictions and 
divisions are formed in these epithelial proliferations which finally produce the picture 



398 



GYNECOLOGICAL DIAGNOSIS 



II is to ^be remembere'l 
luniina of the original 
the periphery, cjiusiiig a 



i 






» ' . J, - V ■* / 

*"_" ""^ ■/ / .^J 



of fenestration (Fig. 234). To these forms, whieh occur frequently in uterine, and 

rarely in cervical cancer or cancer of (he vaginal portion, the descriplivo term 

carcinoma glandula, re fenestra, tum may be applied. Another change 

tliat lakes place in tlie uterine ei>i(iielium may be lilcened (o a ribbon 

with an open-work lace edging (I'ig. 235). 'ihe pi'oliferation is irrcgn- 
Kibbou Cancer . ' .^ "^ \ '^ . ,. . . ' i- i j 

a Subvariety of lav; ui one place small papillary elevations adjoming larger ones which do 

the Fenestrated not, howevor, exceed a cerla,in height — about ten cells. The picture, which 
^^"^ is more distinct in longitudinal sections, is at first papillary; (lie epithelial 

points become connected with one another, and an edging of epithelium coiilaining 
gaps or alveoli is produced along the ^\■a.ll. This variety of cancer has received 
the descriptive name of c a r c i n o m a g 1 a n d u 1 a r e p a p i 1 1 a r e a 1 v e o 1 a r e . 

Ihal this ei)i(helial ijrocess wiiich lakes place in the 
glanils is a.ccompanied by numerous j)roliferations at 
ten- to twelve-fold enlargement of the original lumen. 
I'he membrana propria of the gland, wliich is at first 
preserved even in malignant proliferalions, is finally 
destroyed. The presence of a membrana propria is 
not even against the malignant nature of (he epi- 
thelial process going on in (lie interior of tlic gland. 
It maybe destroyed when the proliferation is benign 
and, conversely, may survive for some time after 
malignant d(>generation has set in. It is not only 
important, but interesting as well to learn the dilTer- 
ent forms which carcinoma — malignant epithelial 
formation — assumes in different portions of (he organ. 
There are some cancer forms that are seen almost 
exclusively in the body; others practically only in 
the cervix; and still others that are confined to the 
vaginal portion. Mention should also be made of a 
form of cancer in which the metaplasia of the cylin- 
drical cpitheliun\ into squamous epithelium is particu- 
larly marked, although in the above-described varieties 
the epithelium in the main loses its cylindrical cliar- 
acter; nevertheless, the proliferating cylindrical epi- 
thelium still suggests its original shape — an im])re.ssion 
which is enhanced by the finely granular protojilasm, 
and the faint lingibilily. In this carcinomatous 
change, which is termed metaplasia, the cylin- 
drical i>|iii helium of the uterine gland is not converted into compact, stratified epithelial masses, 
but into elements which strictly resemble squamous epithelium. They are either piled up 
in the regular fashion and form papillary excrescences; or proliferalions of 
Ciirniiioiition Ml siiuauious epithelium are produced, the upper layers undergoing cornifica- 
Kpidi'olivim. ' ''**" ('''g- -'^''^ \\''d\\ the production of 'horns' (cornua c u t anea)— for- 

mations resembling corns — with enormous enlargement of the glands. During 
the first stage this carcinomatous, atypical epithelial proliferation, which breaks through all 
bounds, resembles benign epithelial changes; it suggests the proliferations of the Gebliard- 
Opitz glands (the glands of pregnancy). The latter, which in a sense represent the 
physiologic prototype of carcinoma, have been often mistaken for malignant degeneration. 
While the above-described malignant stratifications appear firm, coherent and com- 
pact, alterations which present the picture of distinct metaplasia are more loosely joined 
together and seem to desquamate. Metaplasia of the corporeal cylindrical epithelium into 
squamous epithelium, with subsequent proliferation of the latter, occasionally occurs in the 
deepest portions of the mucous membrane, the nuiscnlaris, and in the epitliclial structures 
which have penetrated into it; in this situation it is undoubtedly autochthonous. Can., 
cerous alteration of the corporeal mucous membrane, known as malignant ade- 
noma, has a peculiar significance and represents a glandular cancer (carcinoma 



.^'Ai- 



/ 



Pio. 231. — The Cylinduual Epithe- 
lium I.S CONVEUTED INTO SrUATIl'lEl) ElM- 

THKt.iuM, but continues nevertheless to 
proliferate in a solid mass, while a part of 
the gland, lined with cylindrical epilholiiini, 
is preserved. (Original.) 




SPECIAL DIACJNOSIS 39f) 

p; 1 !i II (I II 1 a r o , ado no ides, adrnocarciiionia) which has a. (^liaracl-orLslif arcliitec- 
lurc. Whereas in eareiiionialous epidichiini there is an enoniKiiis peripiieral prohfera- 
(ion, liie corporeal eyliiuh-ical epil hriiinu, dii I he dlhcr hand, dovelopH HtratificaMon 
- (lie epithelium is piled up. In nialignanl. aikMionia llie pciiphijral proliferations are 
di.slinctly seen — enormous, boundless epitliolial proliferalion inlo Ihe surrounding struc- 
urcs; the slronia is destroyed and the epitiieliuin advances slowly but steadily, pro- 

dueinsr metastases; but no stratification and no piling up of the elements ,, ,. 

•^ ' 1 r. I Malignant 

occur as in (lie usual picture of carcinoma. The cells proliferate side by Adenoma is 

side, foUowinp; (lie typo of physiologic, growth. Malignant adenomata possess ,"'''"'''''""]'''' 

only one layer of cells; they retain the character of a simple 'glandular' ' MnliKnani, 
strut'ture. For a long time observers failed to recogni/c; this bcu'iuiHo rrolifoniiion of 
the peculiar malignant form of jiroliferation was mistaken for a. benign '"' "'"""• 

process, and the mistake is sometimes made to this day. It is true that, the epitiielium in 
malignant adenoma may differ materially from that seen in benign proliferations, and the 






^^ 



4 




Fig. 232. — Tmc Sthatified Squamous Epithelium Covers the Mucous Membrane of the Body 
AND Sends down Solid I'ukjh (Uanceu Nodes) into the Deeper Tissues. At one end the stratified epi- 
thelium apparently peel.s off (icing-cancer). (Original.) 

appearance alone, the peculiar diffuse staining properties, the size of tlie nuclei and their 
individual differences suffice to indicate malignancy; nevertheles.s tlic individual elements 
are not sufficiently characteristic to form the basis of a positive diagnosis. The change 
in the epithelium does no more than indicate the possibility that a malignant degen- 
eration may be present. In addition to the peculiar change in the protoplasm and in 
the nuclei, there is also noticed an arrangement in two layers, due to the rapid growth of the 
elements and their spreading to make room for one another — a process which can also occur 
in non-malignant proliferations (Fig. 237). While in malignant adenomata of the corporeal 
mucous memlirane the changes in the cell proto[)lasm and in the miclci alone hardly suffice 
to predicate the Ijeginning of malignancy, in the case of malignant adenomata of tlie cervical 
epithelium and of tlie vaginal portion, whicli begin in the glanrh.ilar epithelium of erosions 
and are both much more rare, the change from the originally cervical character is exceedingly 
suspicious, not to say decisive. Cervical or erosion-epithelium that stains diffusely and with 
a washed-out effect, and thus comes to resemble corporeal epithelium, suggests beginning 
malignancy and demands the closest scrutiny. 

Malignant adenoma, like alveolar and glandular cancer, is recognised by its architec- 
ture. It is a glandular cancer with the epitiielium arranged in a single row, like a simple 
glandular formation. There is no specific difference between carcinomata that vary in their 



400 



GYNECOLOGICAL DIAGNOSIS 



outward form; they are merely different manifestations of carcinoma. Transitions may 
occur from one form to another. The epithehiun in malignant adenoma may become 
stratified and assume the type of adenocarcinoma. Different forms may be found side by 
side, — occasionally a malignant adenoma coexisting with a growth in process of conversion 











Fig. 233. — Horny Cancer, Cancroid. The stratified epithelium, after replacing the corporeal mucous 
membrane, sends down numerous epithelial plugs into the deeper tissues which everywhere show epithelial 
pearly bodies (onions). (Original.) 

into adenocarcinoma. The modifications of malignant adenoma will be discussed in 
connection with carcinoma of the uterine body; it is interesting, however, that this form 
of malignant adenoma also possesses a physiologic prototype in benign proliferations. 

The diagnosis between malignant and benign is often decided by tlie location in wliich 
the proliferation begins. The physiologic prototype of malignant adenoma, in the beginning 






■ ■ .,;'*f"'-,,'?5^: .... 

Fig. 234. — a. Cross-section op a Nohmal Gland. 6. Epithelium of Uterine Gland, which 
has proliferated by a process of stratification, becoming irregularly papillary and developing an alveolar 
structure (fenestration). (Original.) 

especially, is glandular endometritis (evertens and invertens), as seen best in the deep layers 
of the mucous membrane near the muscularis. The microscopic picture of glandular ovarian 
tumor would serve for malignant adenoma of the corporeal mucous membrane. A transverse 
section of the abdominal extremity of the tube (if the mucous membrane is hypertrophied) 
looks like a metastasis of a malignant adenoma. Gebhard-Opitz glands of pregnancy 
resemble beginning carcinoma. 




SPECIAL DIAGNOSIS 401 

Special Portion. 

The microscopic diagnosis of carcinoma is based on the architecture — 
the histologic composition. Having described tlie forms of malignant epi- 
thelial (carcinomatous) i)roliferation in the uterus, we shall now describe 
the carcinomata of the various segments of the uterus separately. 

Carcinoma of the vaginal portion presents a triple microscopic 
picture. The usual form is that in which the villous epithelial cords, 
connected with one another, pass down from the surface epithelium 
into the deeper tissues (Waldeyer-Thiersch; comp. Fig. 

ni -ii-i i-ii 1 • Carcinoma of 

220). The epithelial masses, which destroy the tissue m the vaginal 

their downward advance, vary in thickness; the surround- 
ing tissues may be inflamed, or the invaded tissue may be apparently 
unaltered. The simile that the epithelium of the vaginal portion 
in carcinoma appears to be nailed 
fast by the epithelial plugs which 
penetrate the tissue (Spiegelberg) 
is descriptive enough in certain 
cases, but not generally applicable; 
very often the surface epithelium 
is completely destroyed— peeled off 
like the glazing on china-ware — . *'«■ 2^5-— 'I'hk utkrine gland undergoes an 

° _ irregular papillary epithelial proliferation as shown in 

before the true carcinomatous pro- Fig. 2.34, forming fenestra. U resembles a ribbon or 

-.„ . , . „. ,^r>i\ T 1 edging, in contrast to Fig. 2.34 (cross-section), being 

llieratlOn begins (rig. 221). In the spread out horizontally in the longitudinal .section. 

early stages of the latter form the "^'"^ ' 

tissue at the surface of the vaginal portion is apparently only some- 
what irritated and is the seat of small-celled infiltration resembling an 
ulcer. Careful examination, however, shows that in cancer the originally 
narrow epithelial plugs penetrate into the deeper layers, which is 
not the case in simple ulcer. 

Cancroid (or skin cancer) must be regarded a,s a modification of the first or simple 
form, and rarely occurs in the vaginal portion. Epithelial formations resembling onions — 
cancroid pearls or pearly bodies (comp. Fig. 224) — are found. The solid epithelial masses 
of carcinoma of the vaginal portion may disintegrate at the centre, the nuclei 
di.sappear, the cells are destroyed, and cavities are produced within the Cancroid of 

epithelial plugs. The epithelial cords may appear granular. The parts that ''pm^ion 

have undergone central disintegration or necrosis occasionally take the stain 
very intensely, and in the microscopic picture the interior of the epithelial plugs looks as 
if they were injected (comp. Fig. 22.3). As a rule, mas.ses of dead tissue do not stain, 
particularly with alum-carmine; haemalaun is preferable for staining necrotic tissue. 

The second form of cancer of the vaginal portion is the ero- 
sion-carcinoma, in which the cancerous degeneration begins in recent 
erosions of the vaginal portion. The erosions represent benign changes 
with tall cervical cylindrical epithelium sending out tubular depres- 

26 



402 



GYNECOLOGICAL DIAGNOSIS 



sions (erosion-glands), which may penetrate into the tissue of the vagi- 
nal portion. The erosion displaces the stratified surface epithelium 
of the portio vaginalis. As the involvement of the tissue of the portio 




Fig. 236. — Several Adj.\cent Glands have undergone partial cancerous change. The cyUndrical 
epitheUum in some places is converted into stratified squamous epitlielium, or cornified epithelium. The 
glands coalesce ; some of the glands are still normal. (Original.) 

vaginalis becomes greater, the epithelium proliferates also on the sur- 
face and a papillary erosion is produced. Constrictions, secondary 
changes in the erosion-glands, and the retention of secretion lead to the 
production of 'follicular' erosion. The large occluded cysts which often 
occupy the deeper layers or form a protuberance on the surface, giving 

it an irregular appearance, have 







Fig. 237. — The Rapid and Vigorous Growth 
of the epitlielial cells leads to an apparent arrange- 
ment in two layers, due to 'spreading' of the upper 
portions of the cells. (Original.) 



been designated ovula Nabothi. 
Carcinomatous degeneration 
may begin in any one of these forms 
— erosio-simplex, papillaris or 
follicularis (ovulum Nabothi). 
The glandular epithehum of the 
gland becomes stratified and prolif- 
erates, both peripherally and downward, breaking through all bounds. 
The carcinoma beginning in an erosion may retain its glandular char- 
acter (Fig. 238), although the glandular wall is covered by stratified, 
instead of simple epithelium; sometimes erosion-glancls that are onl}^ 
in part carcinomatous are found (comp. Fig. 227). If the stratification 
becomes excessive, the epithelial masses may produce solid plugs. 



SPECIAL DIAGNOSIS 403 

villa Nal:)othi, which are usually round, oval, or flattened fVoiu 
mutual pressure, lined with simple cylindrical epithelium, or cells short- 
ened by the stretching or by cuboidal elements, may, in addition to 
simple stratification, show another modification — before the carcino- 
matous change begins, the epithelium forms fresh papillary or ridge- 
like proliferations. In cancerous change the epithelial plugs which 
originally fill the ovula Nabothi appear to be fixed by connective tissue 
sprouts, growing out of the original wall, and derived from the papillje 
or the ridges (comp. Fig. 238, a). Carcinomatous degeneration may 
occur in the deeper layers, while the superficial tissue still appears to be 
benign. As a rule, however, the malignant process begins at the surface. 




Fig. 238. — The Epithelium op the Erosions which develop at the vaginal portion is converted 
(e) into stratified epithelium and penetrates into the tissue like glands; at (a) is a follicle (ovulurii Nabothi) 
which has become carcinomatous (erosion-carcinoma). (Original.) 

The third form of cancer of the vaginal portion might be described 
as a sub-variety of the other two, were it not for the peculiar behavior 
of the epithelial proliferation. This is the malignant adenoma of 
the vaginal portion. Instead of the stratified squamous 
epithelium of this region there appears, first, cylindrical A<Smaof 
epithelium with a cervical character — pale, badly staining ''"^ponion' 
cell-body with basal nucleus; in other words, an erosion 
is produced. Next, the proliferation of the tissue leads to the forma- 
tion of papillary erosions, and when the malignant degeneration begins 
the epithelium assumes the character of the corporeal cells — it stains 
diffusely and the nucleus is displaced. This metamorphosis of the 
cervical epithelium with loss of its characteristic properties is, as has 
been stated, a very suspicious process. The malignant degeneration 
then progresses as described above in connection with the histogenesis 
of malignant adenoma. The epithelium does not become stratified; 



404 



GYNECOLOGICAL DIAGNOSIS 




,i^' 



^ 



everywhere the cells are arranged in single layers with proliferation of 
the stroma. The picture seen in the speculum may be that of a papillary 
erosion; as the process goes on, papillary proliferation appears in the 
vaginal portion, first in the neighborhood of the external os. In the 
microscopic picture the cell-cords are closely packed and interlacing, 
like a collection of earth-worms (Fig. 239). Malignant adenoma of 
the vaginal portion is rare; it rapidly infects the upper layers of the 
surrounding tissue and involves the vagina. 

Whjle malignant adenoma of the vaginal portion at first shows little tendency to pene- 
trate downward, and extends more on the surface, which it infects; a different form of gland- 
ular cancer is occasionally observed in which, witliout any special change in the surface, 
glandular structures penetrate the deeper portions of the stroma and often show an external 

resemblance to erosion-glands. The epithelium, how- 
ever, is variable, stratified, alternating with simple 
cuboidal, flattened, and deeply staining, like swellings in 
various pathologic conditions. Fig. 240 shows a pictui'e 
of this form of adenocarcinoma of the vaginal portion; 
there is something angular in the architecture of the 
preparation. It is often impossible to make a differential 
diagnosis, on which tire ability to make a prognosis and 
to apply suitable treatment depends. A waiting policy 
for tlie purpose of observation, however, may be fatal. 
To the palpating finger an extensive erosion, soft to tlie 
touch, or a sliglitly bleeding ulceration, or — on the other 
hand — an irregular nodular, hard, vaginal portion (due 
to the formation of deep follicles) may appear suspicious. 
Under these circumstances, the diagnosis must be made 
by a microscopic examination of an excised piece, i.e., 
by the histologic composition. Erosions are recognized 
by their typical 'cervical' epithelium — high, badly stain- 
ing cells with basal nuclei; in follicular ovula Nabothi 
the epithelium is cuboidal and, owing to the distention of the cysts, often very low. There are 
no malignant neoplasms of the vaginal portion in which the arrangement in a single row of 
cells predominates and the epithelium at the same time retains its purely cervical character. 
Ulcerations may give rise to great diagnostic difficulties, particularly when there are 
suspicious clinical symptoms, such as hemorrhage and discharge. Cauterization also may 
produce a very suspicious appearance. The diagnosis is based on tlie fact that the micro- 
scopic picture is made up of small-celled material. Ulcers, in addition, show 
marked proliferation of the vessels, whicli, with their tliin walls, are close to 
the surface of the ulcer and rupture at the slightest toucli or during movement 
of the part; often there is no recognizable or imaginable cause for their 
It is difficult, not to say impossible, to identify a syphilitic ulcer by 
the microscopic picture. All that can be done is to decide between benign and malignant. 
No reports are as yet available in regard to the spirochsete pallida in ulcera- 
tions of the cervix. Tuberculous ulcers may be identified by 
finding tulsercle bacilli; in practice, however, a positive diagnosis is very 
difficult. In regard to the diagnostic value of giant cells, see the description and illustrations 
of ulcers in tuberculous endometritis. Under these circumstances also, the main problem 
is to decide between malignant and benign degeneration. Pressure ulcers, 
due to the use of pessaries, may arouse a suspicion of carcinoma in prolapse, 
and in the presence of decubital ulcers at the vaginal portion. The diagnosis 
may be made by excising a piece and submitting it to a liistologic examination. In addition 
to true ulceration of the vaginal portion, so-called erosion-ulcers may result from 



J 



Fig. 239. — Conversion of Papil- 
lary Erosion into a Malignant 
Adenoma (resembling a collection of 
(earth-worms). (Original.) 



Ulcerations on 
the Vaginal 
Portion. 

producrion. 



Syphilitic 
Ulcer. 



Tuberculous 
Ulcer. 



SPECIAL DIAGNOSIS 



405 



intense inflammatory infiltration of a simple erosion, or from improper treatment of various 
kinds. The suspicion of carcinoma is dispelled by finding a small-celled infiltration and 
erosion-glands, and by tlie absence of epitlielial ne\\i-formation. Small myomata or 
fibromata (fibromyomata) occasionally Irave to be examined under the 
microscope in order to exclude malignancy. Papilloma t a, nodular, Erosion-ulcers 
irregular proliferations, racemose formations, cauliflower growtlis, which '^Po'rtion. 

appear suspicious and are therefore removed, also occur in the vaginal 
portion. A careful examination should be made after the operation as, in the first place, 
the microscopic picture may determine whether the growth is a carcinoma, a sarcoma, or 
a carcinosarcoma; and, in the second place, whether the incision has been 
carried into sound tissue. The question of carcinoma is decided entirely by Papilloma of 

the liistologic picture. In sarcoma the malignant changes are found within Portion, 

the connective tissue and stroma. Sarcoma is a malignant neoplasm of con- 
nective tissue, and the simple stroma elements may gradually be converted into large, exces- 
sively hypertropliied cells. Very much enlarged, deeply staining, round or irregular nuclei 




^ q'Ai|I 



Fig. 240. — Peculiah Form of Adenocarcinoma of the Vaginal Portion. The irregular proliferation of 
the epithelium gives an angular appearance to the picture. (Original, j 

point to sarcomatous degeneration. In the microscopic pictiu-e the irregularity of the exces- 
sively enlarged stroma elements is also noticeable. In addition to sarcomatous degeneration, 
glandular structures may occur in the neoplasm and exhibit malignant 
degeneration ; this combination is called carcinosarcoma (Fig. Sarcoma of 

241). The microscopic composition, and hence also the diagnosis, is Portion, 

important, inasmuch as the prognosis in sarcomatous degeneration of the 
vaginal portion is more grave than that of carcinoma, although the operation may have 
appeared to be radical. There are rare cases of sarcoma of the vaginal portion which 
show a kind of node-formation (circumscribed round nodes); the sarcoma in these cases 
is usually a small-celled, round-celled sarcoma. 

When the differential diagnosis presents difficulties, it is neces- 
sary for the examining physician to resort to the microscope for 
confirmation of the diagnosis. The histologic composition decides 
between malignancy and non-malignancy. 



406 



GYNECOLOGICAL DIAGNOSIS 



Carcinosar- 
Goma of the 
Vaginal Portion: 
Difficulties 
Presented by 
the Microscopic 
Picture. 



an erosion- 
pictures of 









Certain difficulties with which the diagnosis occasionally has to 
contend in the microscopic picture remain to be mentioned. A knowl- 
edge of these pictures, which simulate carcinoma, and constant practice 
will enable the examiner to overcome these difficulties. Since 
there are physiologic prototypes of carcinoma, it is impor- 
tant to know from what situation the material to be exam- 
ined has been obtained. At the vaginal portion the most 
important condition in this respect is the healing process of 
-so-called epidermidalization. Aside from this, the 
verrucose proliferations (warts, condylomata) must be 

reckoned with. AVith regard to the 
microscopic picture of the healing 
process in an erosion, the cylin- 
drical epithelium which in erosions 
covers the surface instead of the 
original stratified squamous epi- 
thelium and lines the erosion- 
glands, is gradually converted back 
again into stratified epithelium — 
at first there are two or three 
layers of cylindrical and cuboidal 
cells, then the elements become 
more flat, until the thickness of 
the surrounding epithelial layer is 
attained. A similar metamorphosis 
takes place in the epithelium of 
the erosion-glands. The conver- 
sion of the simple cylindrical into 
stratified epithelium leads to the 
production of solid epithelial plugs. 
These gradually separate and be- 
come smaller, until finally they are no thicker than the surrounding 
epithelium. In this way complete healing of the erosion takes place. 
The plugs formed by the stratification of the epithelium may, in longi- 
tudinal sections, easily be mistaken for the beginnings of 

Epidermidaliza- 
tion Simulating an epithelial malignant depression, whereas they merely 

Cancer. i r- i • i • t 

represent the final stage m the reparative process, in one 
case it is a simple conversion with regeneration; in the other, a 
gradual, boundless proliferation. In flat cross-sections the erosion- 
glands may appear as solid epithelial masses. Epithelial nests lying 
in a corresponding gap in the tissue (in the alveolus) simulate the 
picture of carcinoma. Aside from the irregular grouping of the epithe- 
lium in carcinoma, and the variation in the size of the atypical nucleus, 







V* 



^••^1 



Fig. 241. — Papilloma of the Vaginal Poh- 
TION. Tlie surface epitiielium is cuboidal, tlie stroma 
contains large excessively hypertrophied cells with 
large nuclei ; the glands show carcinomatous degen- 
eration (carcinosarcoma). (Original.) 



SPECIAL DIAGNOSIS 407 

it is necessary to demonstrate that the epithehal masses are penetrating 
into the deeper tissues. At first the diagnosis may liave to be reserved. 
Tlie important point is not to mistake tlie soUd epitliehal plugs which 
occur in the healing of erosions for carcinomatous changes. Healing 

In addition to complete healing of an erosion (sanatio of Erosions. 

completa), there is an incomplete healing (sanatio incompleta), 
in which the erosion-glands remain behind in the deeper layers, 
underneath the squamous epithelium of the vaginal portion, which 
has regained its normal character. These glandular remains are 
lined with beautiful cylindrical epithelium of the cervical type which 
have become cystic or follicular (ovula Nabothi) as the result of 
retention of the secretions. Stratification of the cylindrical epithelium 
lining the deep erosion-glands, which exhibit an antler-formation and 
may extend one centimeter below the surface, does not progress beyond 
a certain limit in the healing of an erosion. It may be assumed that in 
the vaginal portion (a different process is observed in polypoid pro- 
liferations) the reparative stratification does not extend much more 
deeph' than the thickness of the normal epithelium. At this level 
stratification in the deep erosion-glands ceases; the part of the gla-nd 
above that level is filled with stratified epithelium, and this solid part 
separates so that the surface again becomes uniform. The lower por- 
tion of the erosion-gland is apparently torn away and remains in the 
tissue, at first drawn out at its upper extremity and pinched off, and 
later becoming rounded. The picture of healing erosion-glands, 
particularly in sanatio incompleta, may in every respect resemble 
the picture of cancerous change in erosion-glands. Unless it can be 
demonstrated that the gland is still progressing downward, the decision 
between beginning carcinoma and the healing process may be impossible; 
under these circumstances also, it is important not to diagnostic,ate 
carcinoma if the picture is merely that of the reparative process. 

The process of so-called epidermidalization is in every respect 
analogous to the healing process observed in erosions. The microscopic 
pictures are the same. It is merely a difference in the name applied 
to the metamorphosis of the surface, which in this case is originally 
covered with cylindrical epithelium, or rather of the epithelial invagi- 
nation of the surface. These processes are observed chiefly 
in ectropion of the cervical mucous membrane (compare ^^''^'t^^^onlt^ 
also polypi) and in the metamorphosis of cylindrical into ^"cot'eredwit^ 
stratified scjuamous epithelium which occurs in the develop- E^^'h h"''^^ 

mental processes of the fetal parts. In ectropion the 
cylindrical is converted into stratified squamous epithelium. The 
cervical mucous membrane, which is at first pinkish with a slightly 
moist sheen, becomes whitish, firm and like epiderm. 



408 GYNECOLOGICAL DIAGNOSIS 

The gradual metamorphosis of the cyhndrical epithehum, which 
originally lines the entire genital tract and at the end of embryonal life 
occasionally survives on the outer surface of the vaginal portion of 
new-born infants — where it is known as congenital erosion (comp. 
Fig. 63, a and h) — is an analogous process. Wherever the cylindrical 
epithelium is present, the vaginal portion appears pinkish with a moist 
sheen, like an erosion in adults, or like the appearance of cervical mucous 
membrane. In new-born infants, if the conversion of the cylindrical 
epithelium is not complete (congenital erosion), the surface is slightly 
papillary and the shallow depressions are later obliterated by stratifica- 
congenitai tlou. Congenital erosion is an incomplete development; 

Erosion. ^^ ^ rule, thc stratified squamous epithelium extends as 

far as the external os, or even into the cervical canal. The microscopic 
picture of a healing erosion — that is to say, the healing of a pathologic 
condition, the picture of ectropion in which the cervical mucous mem- 
brane assumes the character of epiderm, the picture of the conversion 
of cylindrical epithelium into stratified squamous epithelium in embry- 
onal life — is everywhere the same; only the designation is different, 
depending on what condition is to be described. 

So far we have spoken only of the danger of mistaking the picture 
of the healing processes of erosions for the picture of carcinoma. An 
important question is whether the erosions themselves are not to be 
^ ^ . regarded as carcinomatous. In the study of the genesis 

Is Erosion a .... . . . 

Malignant of crosion it is interesting to point out the importance of 

Proliferation ? . . .,. . , . . 

becoming familiar with, and thereby recognizing, the 
changes occurring in certain definite situations. In studying erosions 
we encounter alterations that are not malignant, contrary to the defini- 
tion of carcinoma. If every atypical proliferation that begins in epi- 
thelium and, without respecting the tissue boundaries, penetrates into 
the adjoining tissues (heterotopia, heteroplasia) were carcinomatous, 
then erosions would be malignant proliferations. Erosion is a new- 
formation; cylindrical epithelium takes the place of the original strati- 
fied squamous epithelium; this cylindrical epithelium is often the 
starting-point of considerable proliferation as regards horizontal and 
vertical extension — the proliferated epithelial structures in the deeper 
layers of the tissues occasionally give rise to fresh proliferations, which 
cause considerable destruction of tissue. In spite of the fact that an 
erosion represents an epithelial new-formation, it is not malignant; 
but it may become malignant. The differential diagnosis must be made 
by the epithelium. So long as the epithelium of the erosion-glands 
retains its peculiar cervical type, malignancy can be excluded. A similar 
atypical new-formation of epithelium which does not respect the bound- 
aries of the mucous membrane and which is in no sense malignant, will be 
discussed in connection with the uterine mucous membrane (see below). 



SPECIAL DIAGNOSIS 



409 



Verrucosa Proliferations. Condylomata. — The process in verru- 
cose excrescences consists in proliferation of the papillary body of 
the investing stratified squamous epithelium. There may be various 
etiologic factors. In the microscopic picture, besides the increase in 
the stroma of the papillae, a considerable increase of the investing 
epithelial layer is observed. If the papillary tissue exhibits a dendritic 
structure, and if a thick epithelial layer occupies the recesses of the 
papilla^, there is produced, especially in oblique, flat, and transverse 
sections, a picture of epithelial proliferation which may simulate that 
of beginning carcinoma of the vaginal portion. The investing epithelial 



.-<<t.'l •■'/■". ^r^i^x 







Pig. 242. — The Cervical Epithelitjm is Converted into Stratified Epithelium. The carcinomatous 
glands are greatly dilated and proliferate into the deeper layers (adenocarcinoma). (Original.) 

layer at the base of the verrucose proliferation is usually not thicker 
than the surrounding epithelium, and occasionally dips down some- 
what more deeply. By cutting the sections perpendicular to the sur- 
face, these proliferations of the epithelium and of the papillary body 
can always be recognized as superficial proliferations of the epiderm by 
the fact that they do not extend below a certain level, equiv- 
alent to the thickness of the ordinary squamous epithelium. 
Carcinoma of the vaginal portion, therefore, manifests itself 
in three different forms: 1. Simple alveolar cancer, includ- 
ing as a sub-variety, cancroid. 2. Erosion-carcinoma (glan- 
dular cancer). 3. Malignant adenoma, to which may be added a rare 
form of adenocarcinoma, with irregular swelhng of the epithelium. 
Carcinoma of the cervix, like the preceding, exhibits various 
forms in the microscopic picture. 1. The simplest is that in which 



Carcinoma of 
the Vaginal 
Portion in 
the Microscopic 
Picture Appears 
in Three Dif- 
ferent Forms. 



410 



GYNECOLOGICAL DIAGNOSIS 



the cylindrical epithelium loses its original character arid becomes 
stratified, in which the peripheral extension to the glandular struc- 
ture is retained, and the parietal stratified epithelium 
represents a covering of variable size and thickness (Fig. 
242). The central lumen, which gives the appearance of 
glandular structure, may occasionally disappear, and large 
solid aggregations or plugs of epithelium make their 



Stratification in 
Carcinoma, 
tlie Glandular 
Structure being 
Retained: Ade- 
nocarcinoma. 
Conversion of 
the Epithelial 
Proliferation into 
Solid Cords 
(Alveolar 
Carcinoma).^ 



aggregations 
appearance. Carcinoma of the cervix may begin more 



in the deep layers of the mucous membrane, and com- 
paratively normal mucous membrane may persist over 

the carcinoma. The descriptive terms employed for this variety 

are g 1 a n d u 1 a r and alveolar carcinoma. 

2. The second form is that in which the surface epithelium is 
converted into a thick, stratified epithelial mass, which sends out broad, 

robust strands of epithelium 
into the tissue. These 
strands exhibit an enormous 
development as compared 
with other epithelial plugs 
or strands, and it is often 
impossible to see the entire 
strand in a microscopic field 
without moving the speci- 
men. The form is still glan- 
dular; it is a peculiar 
gigantic growth (gigant- 
ism) (comp. Figs. 223 and 
242). The cervical glands, 

Fig. 243. — Malignant Adenoma of the Cervix; everywhere which are at first preSCrvecl," 
simple cylindrical epitheliun^ (worm-eaten carcinoma). (Original.) 

at the same time undergo a 
similar change; sometimes, however, they apparently remain intact, as 
though forgotten among the giant gJands. This form is designated by the 
descriptive term " ic-ing-carcinoma " as, owing to the thick cover- 
ing of epithelium, the surface looks like a cake covered with icing. 

3. Malignant adenoma is a third form. It differs, however, 
in a very important respect from malignant adenoma of the vaginal 

portion and of the body in that no new-formation is 

Carcinoma of 

the Cervix Takes obscrved ou the surfacc. The malignant structures traverse 

the Form of . iii ii-i-i • t ^ 

Malignant the tissue like glandular canals lined with a single layer 

enema. ^^ epithelium (Fig. 243), which no longer retains the 

pronounced cervical type, and may extend as far as the peritoneum. 
The glandular canals form enormous ramifications and retain a 
peculiarly regular arrangement, separated by approximately uniform 




SPECIAL DIAGNOSIS 



411 




fields of stroma tissue. As in the case of lymph-carcinoma, the 
cervical tissue looks worm-eaten, like rotten wood; the curette can 
be carried with ease as far as the peritoneum and the malig- 
nant material scraped out. 
A modification of ma- 
lignant adenoma in which 
the epithelium presents a 
peculiarly uniform arrange- 
ment in two or three rows, 
instead of a single layer of 
cells, is observed more fre- 
quently than the above 
form. The cells may be 
cylindrical (Fig. 244) or 
approximately round (Fig. 
245). This gives the picture 
an appearance which dif- 
fers from that of the car- 
cinomatous forms which are FiQ. 244. — Maognant adenoma of the Cekvix; stratified 

cylindrical epithelium. (Original.) 

usually observed. 1 he 

entire tissue of the cervix may be riddled by these cellular cords, 
and to the naked eye the cross-section may show very little change. 

4. The fourth variety 
.^ follows the lymph channels, 

thereby assuming an irreg- 
ular, retiform appearance, 
with minute intercommuni- 
cating clefts which here and 
there present considerable 
dilatation (comp. Fig. 225). 
The microscopic picture, as 
well as the macroscopic ap- 
pearance and the impression 
produced by the scrapings, 
is that of worm-eaten, rotten 
tissue, which offers very little 
resistance to the curette. 
The term ' worm-eaten carci- 
noma, ' while merely descrip- 
tive, is justifiable as it serves to distinguish this from other forms 
of cancer. Carcinoma occurring in the lymph channels may be 
independent or autochthonous, beginning immediately underneath 
apparently normal, or practically normal epithelium — the malignant 



'^ 



i'. 









m^- 



"0 



"«fei 



Fig. 245. — Malignant Adenoma of the Cervix; uniformly 
stratified epithelium. (Original.) 



412 



GYNECOLOGICAL DIAGNOSIS 



degeneration begins in the endothelium of the lymph vessels (endothe- 
lioma). Or lymph-carcinoma may be secondary and represent con- 
comitant phenomena and neoplasms slowly spreading in the lymph 
channels and infecting the tissues. The latter form is distinguished 
from epithelium (see below) by the fact that the endothelium of the 
lymph vessels and of the lymph clefts is left intact, and takes no part 
in the cancerous process. 

In cervical alterations, as in the case of changes observed in the 
vaginal portion, the examining physician resorts to microscopic exami- 
nation if the differential diagnosis presents difficulties. The c^uestion 
of malignancy is decided by the histologic composition; again, the 
importance of the architecture must be emphasized. 

'^;^^-'^v;>: ^^i .^2-^ ,cy" "^^ ,/pa^-" 



Fig. 246. — Glandular Hyperplasia of the Cervix ; the epithelium is not altered, and the process is 

therefore still benign. (Original.) 

With regard to the difficulties of interpreting the histologic 
picture, what has been said in connection with the vaginal portion 
applies t'o cervical alterations also. 

The cylindrical epithelium of the surface may undergo epider- 
midalization in the presence of ectropion or polypoid proliferation. 
The histologic processes are the same as in the healing of erosions in 
the vaginal portion, and as in epidermidalization of congenital erosions. 
Verrucose formations, such as originate in the papillary bodies of the 
papilla? in the vaginal portion, are practically never observed in the cer- 
vix. — The differential diagnosis between the microscopic picture of lymph- 
carcinoma and that of endothelioma, will be discussed later. — Mention 
should be made of a peculiar glandular change that occurs in the cervix, 
and which occasionally suggests the beginning of an adenocarcinoma — 
a malignant adenoma of the mucous membrane. Here and there among 
the normal or slightly proliferated cervical glands a circumscribed 
proliferation of some of the glands is observed. The glandular trunk 
sends out fresh ramifications. If this proliferation takes place at 



SPECIAL DIAGNOSIS 413 

several points on the glandular trunk, the picture of racemose 
structure is produced (glandular hyperplasia of the cervix, Fig. 246). 
In the present state of our experience glandular proliferations of this 
kind may be regarded as benign or, at the most, as suspicious, so long 
as the distinctly cervical character of the epithelium is retained. 

Carcinoma of the uterine body also appears in various forms. 
To begin with, the epithelium of the uterine glands undergoes magnifi- 
cation and stratification of a fairly regular kind. The ^ . 

_ , . Carcinoma 

cvlindrical epithelium, as always during stratification, of the Body 

1 ' • • • T 1 11 • 1 4 1 i °^ "^® Uterus. 

loses its original shape and becomes irregular. As a result 
of this stratification, solid epithelial structures (cancer nests) ma}' be 
produced (alveolar carcinoma); or a more or less centrally situated 
lumen may be preserved, in which case the picture of 

111 . , ^ . V. 11A The Cylindrical 

glandular carcinoma (adenocarcinoma) is produced. As Epithelium in 
in other forms of carcinoma, the superficial layers may Body'^Becomes 
remain normal and the carcinoma may begin in the deeper ^\a^r 'careinomtx 
lavers. This form, in which the carcinoma begins below „ °^,^,*'*''i°^ '*^ 

- ' " (jlandular Struc- 

the surface by a gradual conversion and stratification of t"''^ (Adenocar- 

. . . . cinoma). 

the originally cylindrical epithelium — the mucous mem- 
brane remaining entirely normal — is interesting in the study of the 
architecture of carcinoma, as well as, in a certain sense, in connection 
with the etiology. Here again it must be emphasized that the destruc- 
tion of the membrana propria, which in the later stages is a matter of 
course, is by no means characteristic during the beginning stages of the 
cancer. Epithelial proliferations, and not the destruction of the mem- 
brana propria, betray the carcinomatous nature of the process; the 
membrana propria is destroyed in simple proliferation, particularly 
in necrobiotic processes of glands, and therefore proves nothing; or 
at least, is not in itself a proof of malignanc}'. 

The second form is the icing-carcinoma (Fig. 232). Large 
portions of the corporeal mucous membrane — sometimes insular areas 
surrounded by apparently normal mucosa — or the entire surface, 
present even to the naked eye a different appearance on 
account of the whitish-gray, translucent (opaque) color, is converted 
and the impression of rigidity, from that of the normal 
pink, velvety, delicate mucosa. In the microscopic picture the delicate, 
simple C3dinclrical epithelium is converted into a thick, stratified epi- 
thelial mass in which the individual elements cannot be .recognized; 
these thick epithehal coverings send down epithelial plugs below the 
surface, which form robust proliferating masses throughout the cor- 
poreal tissue. The uterine glands usually disappear completely; rarely 
a few intact glands are seen among the carcinoma plugs. A noteworthy 
feature of the latter is that they show no carcinomatous change such 



414 GYNECOLOGICAL DIAGNOSIS 

as has Deen described; they apparently do not become involved 
in this form of cancer, and seemingly die a passive death. The 
thick epithelial mass on the surface appears peeled off at the edge, 
like a stream of lava; the epithelial mass is pom'ed out on the surface 
and slowly rolls onward. , 

The third variety is the so-called horny cancer (cancroid 
of the uterine mucosa, Fig. 233). It resembles the two former by the 
fact that the epithelial proliferation also leads to the production of 
robust, apparently firm, solid cancer plugs, in contrast 
Se'^B^Xxlkes ^^ ^'^^^ adcnold forms, which will be described later. The 
the Form of a epithelial surface, which has been converted into a thick, 

Horny Cancer. '■ ■ ' _ ' 

solid epithelial mass, sends out sohd plugs below the sur- 
face; everywhere, even in the smallest plugs, onion-hke structures 
(epithelial pearly bodies, cancroid pearly bodies) are present. This form 
of cancer in every respect resembles that of cancroid of the external skin. 
In contrast to these three forms of cancer, we have a fourth 
variety in which the architecture is adenoid. The pictures in this 
form are more graceful in comparison with the more or less solid struc- 
ture of the cancer plugs. Among adenoid cancers two forms 
stmrt"'rein ^^ Very different appearance are distinguished: (a) the 
Cancer of slmplc glandular form (adenocarcinoma, adenocarcinoma 

the Body. i o > 

fenestratum, carcinoma glandulare. Fig. 227); (b) the 
so-called malignant adenoma, which is separated from the other car- 
cinomata and described by a different name on account of the peculiar 
arrangement of the cells, in one layer (Fig. 234). With regard to the 
first group (a), we may refer to what has been said in the beginning of 
the chapter. The epithelium of the uterine glands proliferates and the 
glands become enlarged and dilated, but the proliferation is not uniform 
in every part of the glandular lumen; papillary projections of varying 
lengths are produced, and may unite with similar projections, either of 
the same, or the opposite wall, producing alveoli or fenestrse in the 
epithelial mass, — the so-called fenestrated or ribbon-shaped cancers 
(Figs. 234 and 235). The newly-formed cells are more delicate, and 
the structure appears softer in comparison with the solid architecture 
of the first three forms. Great interest attaches to the pictures in which 
the carcinomatous metamorphosis occurs only in certain portions of 
the enlarged glands, leaving some parts of the glandular wall covered 
with apparently normal epithelium; in these pictures the change in 
the nuclei and in the tingibility between degenerated and not yet degen- 
erated normal cells, is very conspicuous. These glandular changes, 
even in the glands below the surface in the muscularis, show very clearly 
the metaplasia of the original C3dindrical epithelium (Fig. 236), 
along with the alteration of the nucleus and protoplasm; the cylindrical 



SPECIAL DIAGNOSIS 415 

cells become cuboidal and irregular, and are finally converted into 
squamous epithelium with cornification. In the lumen of the gland, 
the metaplastic cells look like epithelial horns of the external skin, 
like miniature cornua cutanea; accordingly, this variety 

' '^ •' ' _ -^ Metaplasia of 

of cancerous change exhibits not only proliferation, but the cylindrical 

• rrn i i i ■ i r- Epithelium in 

also desquamation. The cancerous glands, which at hrst cancer of 

are still separated, approach one another by peripheral 
extension, and may become confluent. In these adenoid forms it is 
often impossible to distinguish any alveolar spaces; everything is 
cancerous, and it is difficult to find the characteristic cancerous change — 
the alveolar structure with the alveoli filled with epithelial prolifera- 
tions. The expert pathologist will waste no time looking for alveolar 
structure; his knowledge of these alterations enables him to recognize 
the carcinoma directly. 

With regard to (b) — adenoid carcinoma of the body or malignant 
adenoma — the name adenoma has been retained because the tumor 
frequently appears simply glandular, although not so in reality. This 
variety of cancer has often been mistaken for a simple 

Carcinoma of 

adenomatous benign glandular proliferation, even by the Body in 

. Ti/TT 1 • • Ti t'^® Form of 

pathologists. Malignant adenoma is a carcinoma like Malignant 

those already described, but with a peculiar architecture; enoma. 

the epithehal cells proliferate side by side instead of in layers, with a 
change in the cell forms. As the proliferation is too great to be accom- 
modated in a single plane, papillary, villous proliferations upward, 
downward, and to both sides, are seen in malignant adenoma. The 
epithelial cells may multiply to such an extent that the stroma which 
gives support to the epithelial proliferation cannot keep up, and the 
cells of the proliferated epithelial bands are arranged close together; 
the bases of the cells may even be in contact (the cells are dos-a-dos). 
The stroma occasionally consists of a single connective tissue cell and 
its processes. In cross-section these bands of proliferated epithelium 
appear like long papillae (Fig. 255, b), covered with a single layer of cells. 
The picture is therefore not that of a 'gland' with the stroma outside 
and the cells in the interior (with the cells vis-a-vis); it merely has a 
general 'glandular' appearance. 

When in speaking of malignant adenoma we say a single layer of 
epithelium, we mean that the layer of cells is actually single and almost 
of uniform height, although, as often happens in epithelial proliferations, 
an apparent double formation is produced by the fact that one cell 
has a very small base and the one next to it a broader one with a 
correspondingly thin upper extremity (Fig. 237). At any rate, the 
peculiarity of malignant adenoma of the body consists in a high 
degree of proliferation with only one layer of cells; nevertheless the 



416 



GYNECOLOGICAL DIAGNOSIS 



epithelium does not quite retain the shape and appearance of normal 
epithelium. Aside from the fact that the cells are often exceed- 
ingly narrow from mutual pressure, a change in the nuclei and in 
the protoplasm accompanies the cancerous change. The tingibihty 






Fig. 247. — Schema I, a.- Genesis of Malignant Adenoma of the Body in Longitudinal Section ; Invebt- 

ING Form. (Original.) 

also is somewhat different; the nucleus is longer, narrower, and 
the cell takes the stain in a peculiar, diffluent manner. The alter- 
ation is difficult to describe, but with a httle practice it is very easily 
recognized. In contrast to normal epithelium the cells have a 









Fig. 248. — Scheme I, 6.- Genesis of Malignant Adenoma op the Body in Teansverse Section ; Invert- 
ing Form. (Original.) 

blurred, turbid appearance; the change cannot be seen so well in 
a single cell as in a whole row, and the architecture as a whole 
is peculiar. The original uterine gland in the degeneration of malig- 
nant adenoma is destroyed by the enormous epithelial proliferation 
which goes on in all directions. The proliferation may be in a single 
direction for a considerable distance, producing a peculiar uniform 



SPECIAL DIAGNOSIS 



417 



appearance: cords of cylindrical epithelial cells are found side by side 
at uniform distances from one another; again the enormous epithelial 
prohferation may take place in various directions, every part of the 
epithelial cord becoming the starting point of a fresh proliferation, 
producing the greatest irregularity, 
the cell cords interlacing in every 
direction. Hence to the inexpe- 
rienced observer the regular forms 
of malignant adenoma appear like 
an entirely different process from 
the irregular, tangled proliferations. 
In the latter, the picture resem- 
bles a tangled coil of earth-worms, 
while in the former the architec- 
ture is more regular and more 
glandular (gland by gland). 




1^ 



i^ 




Fig. 249. — Cross-section from a Malignant 
Adenoma of the Body ; Everting Form. The site 
of the original lumina of the glands can still be 
recognized. (Original.) 



Familiarity with malignant adenoma 
may be aeqviired by studying the process of 
proliferation in various glands in schematic 

form. In Scheme I, a (Fig. 247), a normal gland is shown in longitudinal section. The 
small epithelial elevations in all parts of the gland gradually increase in size, becoming 
both longer and narrower, and in turn bring forth papillary elevations. As a result, 

^^ 







Fig. 250. — Scheme II, a: Genesis of Malignant Adenoma of the Body in Longitudinal Section; 

Everting Form. (Original.) 

the normal gland becomes considerably dilated and enlarged, and is converted into a mass of 
cell tubes by this intraglandular proliferation. There is no end to this form of malignant 
epithelial proliferation, which continues to destroy first the immediate neighborhood, then the 
more distant regions, then the entire organ, and finally by metastases and cachexia, the entire 
body. Scheme I, b (Fig. 248) shows in cross-section the change that takes place in the normal 
lumen as the result of intraglandular proliferation — the continuous sprouting of fresh 
27 



418 



GYNECOLOGICAL DL4GNOSIS 



Inverting 
Adenoma. 



epithelial cords. The gland becomes enormously dilated by proliferation into the neigh- 
boring tissue, the lumen is filled with epithelial cords beyond the limits of the original 
gland, and these cords are everywhere covered with a single layer of epithelium. These epi- 
thelial proliferations which begin in individual glands are easily recognized 
and readily traced if the stronia between the glands is still preserved in 
some degree; but if the degenerated glands are in immediate contact with 
one another, it is impossible to trace the epithelial proliferations back to a single gland; 
instead, disorderly, tangled and matted cords of epithelium (resembling a whorl of earth- 
worms. Fig. 239) are produced. If even beginning stratification develops at certain points 
— since malignant adenoma merely represents a peculiar architectural variety and not a 

specific unalterable formation — a glandular 



c 




'■^r^ 




Fig. 251. — Scheme II, 6.- Genesis of 
Malignant Adenoma or the Body in Cross- 
Section ; Everting Form. (Original.) 



carcinoma derived from malignant adenoma 
results. Ultimately the pictiue of mahgnant 
adenoma may be entirely obscured. Malignant 
adenoma is a carcinoma of peculiar architec- 
ture. The proliferation of the cells continues 
for a long time or altogether in a single layer; 
but at any moment tliis single layer may be 
replaced by stratification. Malignant adenoma 
may at any time be converted into the other 
forms of glandular carcinoma. 




Fig. 252. — Longitudinal Section of a M.\- 
lignant Adenoma of the Body ; Everting Form : 
somewhat irregular, 'ghostly,' glandular arrange- 
ment. (Original.) 



Everting 
Adenoma. 



There is another form of malignant adenoma which is glandiJar throughout, showing 
genuine gland-tubes in longitucUnal and cross-section, and in wliich the stroma siurounds the 
cells, instead of the cells being attached to the stroma. These forms of malignant adenoma are 
illustrated in Scheme II, a, in longitudinal section (Fig. 250), and b, in cross 
section. Scheme II, a, shows the normal gland in longitudinal section. Small 
eversions or evaginations are produced at every point in the periphery of 
the gland, gradually becoming larger, and continue to ramify by producing fm'ther evagi- 
nations. The normal gland appai-ently remains in the centre and becomes surroimded with 
glandular ramifications. This malignant proliferation continues to spread indefinitely, ulti- 
mately destroying the surrounding tissue, the organ, and by metastases and cachexia, the 
entire body. If the proliferations which begin in individual glands are separated by stroma, 
the genesis of the growth in individual glands is simple and readily seen. If the glandular 
ramifications invade the domain of adjoining, likewise degenerated, glands and the lumina 
of the glands are side by side, and one glandular proliferation in contact with the next, the 



SPECIAL DIAGNOSIS 



419 



origin of the growtli in individual glands can no longer be demonstrated. The glandular 
lamina of the glands themselves are in contact, and the cells of the individual glands are 
ahnost back to back (dos-a-dos). This form of malignant adenoma, which is termed 
everting to distinguish it from the inverting form produced by intraglandular 
proliferation, retains its peculiar feature — the arrangement of the cells in a single layer — 
lona;er than the inverting form; but since 



the differences are not specific, and these 
tumors merely represent different forms 
of the carcinomatous architecture, strati- 
fication may ultimately develop here and 
there, and everting malignant adenoma 
may also occasionally be converted into 
a glandular carcinoma. In cross-sections 
the change is clearly seen to be due to 
the evagination; the apparently normal 
round or oval lumen of the gland — the 
'mother gland' — is hardly changed at the 
centre, while around it the tissue is every- 
where infiltrated by the radiating glan- 
dular sprouts. In Scheme II, b (Fig. 251) 
the original lumen for the sake of clear- 



^E? a 




K,jm 




Fig. 253. — Everting Malignant Adenoma, a. Particle obtained with the curette ; 6. magnified about ten 
times ; c. magnified about twenty-five times. (Original.) 



ness is drawn in somewhat heavier outline than the remainder of the picture. It may also 
be remembered in studying malignant adenoma that combinations of the intraglandular 
and extraglandular forms may occur, and that the two processes may be present in the 
same, or in adjoining glands alternately. This explains why it is not always possible to 
make every strand of epithelial cells, every glandular form of cancer, correspond strictly to 
one or the other scheme. If it is also remembered that malignant adenoma is merely a 
cancer of pecviliar architecture which is capable of being converted into other forms of carci- 



420 



GYNECOLOGICAL DIAGNOSIS 



noma, it will not be difficult to differentiate it from these other forms; hence a malignant 
adenoma may gi^'e rise to a glandular carcinoma (adenocarcinoma, or carcinoma adenoides) 
and, if the cell proliferation continues, to a cancer with solid plugs and alveolar carcinoma. 



a 




/* 



* 






'-_■ ^V- ^e i£]r^~rr^ 




7) 



-^^Vfc^ 



.'-^-/'iir a 



Fig. 254.- 



-Two TJtebine Glands in Processes of Malignant Degeneration (inverting malignant ade- 
noma). At one point of the wall, a, combined with the everting form. (Original.) 



In view of the importance of properly recognizing the various forms, I have chosen for 
illustration a particle of tissue (Fig. 253), a, natural size; b, magnified approximately ten 
diameters, in which the malignant structure is already clearly seen; and c, magnified twenty- 
five times, in which the details of everting malignant adenoma are fully recognizable. In 






m 



'fc 



Fig. 255. — Malignant Adenoma, under higher magnification: a, approximately longitudinal section ; 6, 
approximately transverse section (inverting form). (Original.) 







Fig. 254 two contiguous glands of a malignant adenoma are represented, which sufficiently 
show what an amount of epithelial destruction takes place if, instead of two, innumerable 
glands altered in tliis way are present side by side. Finally, in Fig. 255, a and b, the inverting 
type of malignant adenoma is shown in liigh magnification. 

Another liistologic point is that in malignant adenoma the nuclear figures retain a 
direction corresponding to the side by side proliferation of the cells; the Une of division 



SPECIAL DIAGNOSIS 421 

is parallel to the base of the cell, not, as is ordinarily the case when the cells are piled up on 
each other, in a direction more or less vertical to the base (Amann). 

A lymph -carcinoma is a carcinoma in which the lymph channels continue to 
proliferate, like the cancers of the vaginal portion and the cervix, which are designated worm- 
eaten on accoimt of their resemblance to honph vessels; they are rarely seen in the body. 

In reviewing the histologic pictures of carcinoma of the uterus 
we are struck, first, by the great variety in the external appearance of 
the pictures; and, secondly, by the fact that in the main 
each segment of the uterus — the vaginal portion, the cer- observed in 
vix and the body — possesses its individual form of cancer. of can^r 

Malignant adenoma is found chiefly in the body, is rare in '^""he^varfous 
the cervix, and still rarer in the vaginal portion. In the ^thTuterus^ 
cervix it occurs practically only in the form of everting ade- 
noma. The 'worm-eaten' variety occurs rarely in the body, still more 
rarely in the vaginal portion, and more frequently in the cervix. Glan- 
dular forms of the fenestrated type are practically seen only in the body. 

Owing to the great multiplicity of forms, it is necessary to be 
able to recognize the individual forms in order to avoid mistakes 
in comparing them with the pictures of carcinoma in other organs. 
This applies particularly to malignant adenoma, which has been so often 
incorrectly interpreted. Another important point is that the situation 
of the cancer in the uterus can be determined, if not with absolute 
certainty, at least with great probability, from the microscopic picture. 

With regard to the nomenclature, it may be added that carcino- 
mata with solid epithelial masses are usually called alveolar; car- 
cinomata with a central lumen are termed glandular (adenocarci- 
noma) on account of their resemblance to the structure of 
glands. These terms are merely descriptive, for a central 
lumen may be produced in a single large alveolar cancer 'secondarily,' 
i.e., as the result of central degeneration; hence the expression 'glan- 
dular' does not always indicate the origin of the carcinoma. Malignant 
adenoma is a cancer with a single layer of epithelial cells, which may 
be converted into a carcinoma with stratified epithelium (adenocar- 
cinoma), or even, especially the everting form, into an alveolar cancer. 
The description of a microscopic preparation must be such that it will 
at once produce in the hearer a mental picture of the preparation. 

Malignant Syncytioma (Malignant Chorio=epithelioma). 

A discussion of cancer of the uterine body must also include one 
other malignant neoplasm which differs from most other neoplasms by 
certain definite properties not observed in any other — the malignant 
syncytioma (carcinoma syncytiale, Kossman; malignant chorio-epi- 
thelioma, Marchand). In the first place, malignant syncytioma has 



422 GYNECOLOGICAL DIAGNOSIS 

a definite etiology. Since it originates in the epithelial covering of the 
fetal villi, it cannot occur without pregnancy; it is possible only at 
certain periods of a woman's sexual life; it does not occur before sexual 
Malignant maturity, nor after the power to conceive has ceased. It is 

Syncytioma. characterized by its definite seat in the genital tract, 
namely, in the body or in the tube, although it may also develop in the 
abdomen (abdominal pregnancy), or in the ovary (ovarian pregnancy). 
Other exceedingly interesting points about malignant syncytioma are 
its development from fetal, instead of maternal tissues, often degenerated 
in the very earliest stage of pregnancy, and that the neoplasm which 
ultimately destroys the mother's life remains until the end a fetal 
neoplasm composed of fetal elements. 

„ , The unique position of maliarnant syncytioma remains unshaken, althousrh 

So-called , , , ■ ■ , ,• ■ f , , , , •, , 

Chorio-epi- several cases o: chono-epithehoma in the male liave been described; cases 

thelioma in the therefore in which there was no pregnancy, and in wliich other peculiarities 
be^Desi"nated °^ feminine malignant syncytioma were impossible. Chorio-epithelioma in 
Syncytioma the male is intensely malignant; whether the choice of the name is justi- 
Ectodermale ^^^ ^^.jy j^^^^ j^g discussed in this place. So far, fetal villi have never been 
(Masoulinum). ' i 

demonstrated in man; in the histologic composition the tumors appear to 

be absolutely identical; the neoplasm originates in ectodermal elements; it is a masculine 
ectodermal malignant syncytioma, not a malignant chorio-epithelioma. 

Malignant syncytioma in woman is a malignant neoplasm of the epithelial covering 
of the fetal villi — a true malignant chorio-epithelioma. 

For the histologic composition of the villi the reader is referred to the section on the 

Microscopic Diagnosis of Pregnancy. In the placental villi, we distinguish the connective 

tissue portion which accommodates the blood-vessels and the epithelial 

The Epithehal investment. The epithelial investment in turn is composed of the ectodermal 

Covering of the ^ ' 

Villi is Com- layer in immediate contact with the stroma of the viUi and the syncytial 

posed of an Ec- layer which covers all the chorionic villi. Both portions of the epithelial 
Syncytial Layer, investment are of fetal origin; the lower, which is in contact with the stroma 

of the villi, and is known as the layer of Langhans, must be regarded 
as the matrix of the upper, syncytial layer (Spuler). The layer of Langhans consists of round, 
translucent, faintly staining elements, with round, well staining nuclei, often looking like 
squamous epithelium in the microscopic picture. The syncytial layer, finely gran- 
ular and containing small vacuoles, readily takes the stain; the nuclei are round and also 
stain deeply. As the name 'syncytial' indicates, the individual cells cannot be differentiated. 
The villi are attached by means of their investment to the decidua basilaris; the epithelial 
covering may either be destroyed at the point of attachment, or it may invade the decidua 
basilaris, first in tlie form of fine protoplasmic fibres like rootlets, or root fibres, and later 
in the form of larger elements with fairly well staining protoplasm, and deeply staining, 
large nuclei. The syncytium is apparently dissolved into individual cells which often retain 
a connection with each other by means of delicate tlireads of protoplasm. The ectodermal 
cells take part — sometimes to a considerable degree — in this proliferative process. 

These fetal cellular elements, which are often found at a considerable depth in the de- 
cidua basilaris and also penetrate into the muscularis and into tlie vessels, are called 

syncytial wander-cells. Both varieties, syncytial and ectodermal, 
Wander-cells *^^^® P^''* '" *'^'® tissue invasion. In the earliest period of pregnancy a 

considerable proliferation takes place in the epithelial investment of the 
villous trunk (in the intervillous space), as also in the tips of the villi at the point where they 
are attached to the decidua basilaris; nodular formations resembling miliary tubercles are 
formed. This proliferation of the epithelial investment is found chiefly in hydatidiform 
mole. In severe myomatous degeneration of the uterus a very extensive syncytial infiltration 



SPECIAL DIAGNOSIS 423 

of the decidua and ako of the muscularis, extending far into the maternal tissue, has been 
observed (Rob. lleyer). All these prohferations are benign in character. They repre-sent 
brief, temporary' conditions or processes, and we may therefore speak of a benign ectodermal 
syncj-tioma (benign chorio -epithelioma). 

But the constituents of the epithelial investment of the fetal viUi may also undergo a 
malignant degeneration. In a very short time, after abortion, after hydatid 
mole, or even during pregnancy when the uterus is not yet evacuated, metastases may make 
their appearance in all the organs; in the vagina in the form of large, bluish-red tumors; 
metastases may app)ear in the lungs and in the brain; indeed even the spleen and liver may 
be attacked. In addition to this fulminating variety, in which everything is lost before one 
has time to think whether an intervention or complete extirpation is necessarj^ there are cases 
which progress more slowly. Often a microscopic examination gives the first hint that the con- 
dition is a sequel of pregnancy, at a time when pregnancy apparently no longer enters into the 
question at aU; indeed, it seems that spontaneous recoverj' also sometimes occurs. To F. Mar- 
chand is due the credit of being the first to give a clear description of this malignant tumor. 

The microscopic picture of malignant syncytioma contains nothing 
but syncytial masses (syncytial derivatives and ectodermal elements), 
and among them, and surrounded by them, are here and there blood- 
spaces containing maternal blood fFig. 256). To make the examination 
more difficult, the remains of the neoplasm are distinctly recogni- 
zable only at the periphery of large necrotic masses or blood clots, so 
that in individual cases the condition might be mistaken for a vaginal 
hematoma, were it not that the clinical picture and the presence of a 
few sj^ncytial and ectodermal masses at the periphery of the blood- 
spaces point to the true nature of the neoplasm. The necrotic, friable, 
reddish-yellow, often chees}', dry masses show, in addition to the changes 
in the blood clots, the traces of syncytial elements that have died and 
are no longer capable of taking the stain — have become homogeneous 
and broken up into delicate fibres; while at the peripher}' the neoplasm 
itself continues to spread or gives rise to metastases. Malignant sjm- 
cytioma spreads by way of the blood channels. "Whereas it appears 
that large blood clots, hemorrhages, necrotic masses, and S5mc3'tial 
elements, as well as necrotic particles, belong to the genuine picture of 
syncytioma, one also sees proliferations and metastases in which the 
cellular architecture plays the most important role. Syncytial masses 
are surrounded by large accumulations of ectodermal cells and look 
like large, long-drawn-out giant-cells — protoplasmic masses, often 
containing but a few nuclei of a finely granular structure with vacuoles 
of various sizes — sometimes they are provided ■ndth numbers of pro- 
toplasmic processes, which may communicate with other syncytial 
masses. Formerh^, before this neoplasm was known, it was frequently 
mistaken for a giant-cell sarcoma. Conversely, the syncytial masses 
may be so abundant and arranged in such a way as to include 
the scanty ectodermal cells; the latter have a pale, faintly staining 
cell-body, well staining nucleus, and are variable in size. By pres- 
sure they are often flattened so as to appear almost hexagonal, or 



424 



GYNECOLOGICAL DIAGNOSIS 



their contour may be so sharp as to suggest vegetable cells. They 
also contain karyokinetic figures. Thus either the syncytial masses 
or the epithelial cells may preponderate; neoplasms consisting 
entirely of ectodermal cells have also been described. 




^)^' 






^ 






Fig. 256. — Maxignant Stncytioma; Syncytial and ectodermal constituents, blood-spaces ; metastases from 

the vagina. (Original.) 

Depending on the character of the material submitted for exami- 
nation, the diagnosis may be exceedingl}^ eas}'; but occasionally, if 
only necrotic masses are obtained, or if the particles are 
derived from the periphery and contain only a row of 
single, large syncytial elements resembling the syncytial 
wandering cells of benign syncytioma, the diagnosis may 
be more difficult. The presence of necrotic tissue is more conclusive than 
the individual tumor elements. In simple syncytial wandering cells there 



The Diagnosi; 
of Malignant 
Syncytioma 
Sometimes 
Difficult. 



SPECIAL DIAGNOSIS 425 

is no necrosis, but simple decidual masses infiltrated with large num- 
bers of syncytial wandering cells may also be presented for examination 
along with blood clots in cases of abortion, and may occasion great diffi- 
culties. In the main, a diagnosis of malignant syncytioma 
of syncytioma must be made when, instead of a few syncytial elements, 
i>y the Presence large Conglomerations of cells, whether syncytial or ecto- 
of cenff not''^^ dermal, are found side by side, and appear to have displaced 
Eiements^^ large portions of the tissue. The diagnosis is further con- 

firmed by the destruction of blood-vessels, or by the presence 
of necrotic masses, pointing to a considerable proliferation with subsequent 
destruction. The presence of individual elements, though fairly abundant, 
and infiltrated tissue, is not as yet sufficient to establish malignancy. 







% 






■3* 
if 



1; 



Fig. 257. — Malignant Syncytioma, from a large tumor of the uterine wall. The section contains only 

syncytial derivatives. 

Chorio-epitlielioma, like malignant tumors in general, gives rise to metastases. Metas- 
tasis must be differentiated from deportations of benign proliferations, or rather of villi with 
a benign proliferating investment. These benign deportations are destroyed in the organs 
in which they are found, and the symptoms which result from these embolic particles vary 
according to the importance of the organ. It cannot be assumed that active processes in the 
surrounding tissue take their origin in these benign deportations. The behavior of the sur- 
rounding tissue is determined by its own structure; it may also be possible in exceptional 
cases for an originally benign deportation to undergo malignant degeneration. 

At the present time opinions vary in regard to the metastatic tumors which are often 
observed in the vagina. These are rarely large, of a bluish-red color resembling varices, and 
their operative removal is followed by recovery, although they contained chorio-epithelial 
masses. From the fact that recovery takes place it is inferred that these chorio-epithelial 
masses are benign, although radical removal of all the chorionic constituents is not possible. 
In connection with this diversity of opinion, it is to be remembered that chorio-epithelioma is a 
very peculiar neoplasm with a great tendency to break clown, whether it be benign or already 
malignant, and extirpation of the varix-like nodule is well calculated to bring on necrosis 
of any remaining particfes of the chorio-epithelioma, with ultimate spontaneous recovery. 



426 GYNECOLOGICAL DL4GNOSIS 

The decision of this question is exceedingly important, as it affects the question of 
total extirpation; whether in the case of a metastatic tiunor in the vagina the latter alone 
or the uterus also shall be removed. If one of these vaginal metastases as large as an egg is 
shown by microscopic examination to contain chorionic masses of cells which have apparently 
invaded the tissue, even if recovery subsequently takes place, such large metastatic tumors 
ought to be regarded as malignant. 

With regard to the nomenclature, we have a choice of several names; although a malig- 
nant epithelial neoplasm is usually called carcinoma, malignant syncytioma nevertheless 
differs considerably from carcinoma, both in its structure and in the fact that it is composed 
of two kinds of cells. With regard to the structure, it contains no connective 
omenc ^. "^^^ tissue, the entire tumor being formed of epithelial masses. We may speak 
of two kinds of epithelium, in spite of the fact that one forms the matrix for 
the other. As regards the term malignant chorio-epithelioma there is no objection 
to its employment, although the tumor does not consist primarily of chorio-epithelioma, but 
of ectoderm into which the mesoderm grows secondarily. It is in the latter that the original 
ectoderm is called villous, or chorio-epithelioma. The apparently identical tumors which have 
been demonstrated in man, cannot therefore be properly called chorio-epithelioma, because 
they contain no villi and consist solely of ectodermal proliferation. The term malignant 
syncytioma is appropriate both for the male and for the female, since it means proliferation 
of the ectoderm; it is derived from the most prominent, and apparently most characteristic 
ectodermal constituent— the syncytium. I shall retain the term malignant syncytioma, 
since the name is after all merely a kind of convention to designate definite changes and 
definite properties by a definite name. 

The differential diagnosis has to deal separately with 

Differential . . ... 

Diagnosis: (a) the clifficultics, A, encouiitered by the clinician; and, B, 

for the Clinician; i-i ,,i i ,,i ii- ttt 

(6) for the those which present themselves to the pathologist. We 

at oogist. ^^^ j^^^^ chiefly interested in the latter. 

A. — The clinician encounters certain difficulties in the diagnosis 
of carcinoma of the body. In endometritis severe symptoms 
arousing the suspicion of carcinoma make their appearance; and, on 
the other hand, carcinomata occur without any marked symptoms. 
Macroscopic inspection of the scrapings is inadequate for a positive 
diagnosis; they may be so abundant that the diagnosis of carcinoma 
appears to be clinically positive, whereas microscopic examination 
shows nothing but hyperplastic endometritis; conversely, the quantity 
of scrapings may be so small that no suspicion of mahgnancy is aroused 
clinically, although the condition is in fact malignant. In hyperplastic 
endometritis, the scrapings after appropriate treatment with alcohol, 
preparatory agitation, definitive hardening (see above) by their spongy 
appearance practically exclude the diagnosis of carcinoma, even without 
microscopic examination. A positive decision can, of course, be made 
in such a case only with the microscope. The microscopic picture of 
endometritic changes — be it glandular or interstitial — is so typical 
that there is no difficulty in distinguishing it from the various above- 
described pictures of carcinoma. 

The spongy layer which is found in the deeper portion of the mucous 
membrane in glandular endometritis may occasion more serious diffi- 
culties to the pathologist, who might be inclined to think of mahgnant 



SPECIAL DIAGNOSIS 



427 








% 






adenoma on account of the close apposition of the glands; but the 
connection between the spongy layer and the upper portion of the glands, 
which will be found in other sections, and the prominence of the cylindrical 
epithelium will serve to obviate the difficulty. If there is any doubt, 
several series of sections must be examined, as a study of different prepa- 
rations of the same scrapings will enable one to arrive at a final decision. 

Any one who appreciates the importance of microscopic examina- 
tion will agree that every physician ought, if possible, to submit all 
scrapings to a pathologist if he cannot examine them himself. The 
prognosis, as well as treatment, depends on the diagnosis; as, for 
example, if clinically there 
is a suspicion of malignant 
degeneration and the micro- 
scopic preparation clearly 
shows the glands of preg- 
nancy (Opitz-Gebhard). 
The possibility of mistaking 
the changes of pregnancy in 
the uterine glands for carci- 
noma should be mentioned 
at this point. The structure 
of the epithelial cells in the 
uterine glands during preg- 
nancy suggests carcinoma- 
tous degeneration of glan- 
dular epithelium (Fig. 258). 
From lack of experience even 
prominent pathologists have 
failed to recognize this special 

change in the gravid uterus, and hysterectomies have been performed 
on the strength of this picture of the Opitz-Gebhard glands, which 
merely indicated the postabortum state. 

Portions of expelled and degenerated myomata may be submitted, 
and the diagnosis must be determined by the presence of muscle fibres 
and the absence of other changes. Placental polyps and large placental 
masses have been mistaken clinically for carcinoma, when examination 
showed the microscopic picture of villi with their epithelial investment 
and the large decidual cells, establishing the diagnosis of products or 
alterations of pregnancy. The hysterectomy which was performed on 
the strength of clinical examination alone might have been avoided 
had the glands of pregnancy been demonstrated with the microscope. 
Conversely, in cases in which a clinical diagnosis of abortion has been 
made, the evacuated masses may be found to consist not simply of villi 




Fig. 258. — Alterations of Pregnancy in the Uterine 
Glands. Stratification (piling up of the cells) simulating 
carcinoma ; Opitz-Gebhard glands. 



428 GYNECOLOGICAL DIAGNOSIS 

or decidual remains, but almost exclusively of syncytial tissue, and 
the difficult question has to be decided whether the alteration is malig- 
nant or benign. Simple syncytial wandering cells or ectodermal ele- 
ments would indicate the latter; while large masses of syncytial and 
ectodermal cells, with hemorrhages and necrotic tissue, are more in 
favor of malignant degeneration. The decision of this ciuestion is often 
difficult and may require several examinations. It should also be men- 
tioned that the cellular elements in the decidua cannot always be dis- 
tinctly differentiated as decidual cells or ectodermal cells, as they often 
resemblfe each other very closely; nor has it any great value for the 
decision of malignancy. 

Since we know that malignant syncytioma may follow hydatid- 
iform mole, the question whether this degeneration is present may 
arise after such a mole has been removed from the uterus. The decision 
may be difficult, because if the symptoms are clinically suspicious, the 
finding of many syncytial elements in the curettage might arouse 
a suspicion of beginning malignant degeneration; it is exceedingly 
difficult in such cases to give a decision on microscopic grounds, but it 
is to be borne in mind that as a general rule the presence of individual 
syncytial elements proves nothing, even though they may occasionally 
be present in large numbers. In the decidua and in the highest layers 
of the muscularis malignant degeneration of the villous stroma or of 
the decidual cells in the decidua, does not enter into the differential 
diagnosis. That it occurs has often been maintained, and is not 
impossible; but as yet it has never been proved. Aschoff 
Degeneration of ^^^ rcportcd a casc whlch has a bearing on malignant 
the Villous degeneration of the villous tissue. Neumann has described 

stroma. ° 

invasion of the villous stroma by syncytial elements. 
The statement that, when this occurs after hydatidiform mole, a 
malignant syncytioma is also present, has never been confirmed. 

B. — If the clinician who turns to the pathologist to clear up his 
doubts encounters difficulties in the diagnosis of carcinoma, the pathol- 
ogist himself often has to deal with the most perplexing 

Difficulties in ° . . i • n . . 

the Diagnosis conditious whcu he IS called upon to render a decision in 
Encountered by cUnically doubtful cascs; but practice and familiarity with 

the Pathologist. ,ii-ii- •. ii ,i •,• 

the histologic pictures, as well as repeated examinations 
will usually enable him to accomplish his task. The occasional diffi- 
culties encountered in the diagnosis of malignant syncytioma 
have been referred to, as has also the possibifity of confusing the Opitz- 
stratified Gebhard glands of pregnancy with adenocarcinoma 

Epithelium. (^pjg 258). Scrapings obtained from the body occasion- 
ally contain stratified epithehum which, however, has no malignant 
significance; it may occur in small polypoid proliferations, which it 



SPECIAL DIAGNOSIS 429 

only partially covers. The stratification, usually consisting of only 
two layers, may cover large portions of the mucous membrane uni- 
formly; some individuals appear to have two layers of epithelium 
throughout (Rob. Meyer). Circumscribed stratification „ • • t 

" ^ "^ ' _ Psoriasis of 

occurs in the body, described by von Rosthorn as psoria- the uterine 

. . . . Mucosa. 

SIS, and cases of this kind are always suspicious. The 
differential diagnosis in all cases presenting epithelial stratification 
must be based on the fact that the process is not progressive. Epithelial 
proliferations with stratification occurring in corporeal 
polj'pi are positively malignant only when they extend of Ep'ithtna^ 
beyond the base of the polyp into deeper layers; the fact ^^n^polypil 
that the epithelial covering penetrates into the polypi 
themselves proves nothing. Among the direct sources of error must be 
mentioned the deceptive pictures seen in microscopic preparations; 
oblique and flat sections may produce the appearance of 
solid epithelial formations; flat sections, and sections that picTuresIn 

are too thick, make the fundus of the uterine glands appear preparation's! 
like solid, cellular plugs (comp. microscopic diagnosis of 
endometritis). Oblique sections, especially through ridges or evagina- 
tions of epithelial cells, suggest stratification and may thereby arouse 
a suspicion of beginning malignancy. A careful revision of the pictures, 
with jparticular attention to the direction of the section, and repeated 
examination of sections cut as thin as possible, will enable the examiner 
to make a correct interpretation. What looks like beginning stratifi- 
cation may be shown not to exist by cutting thin sections and carefully 
observing their direction. 



^t5 



Stratification is found much more frequently in the cervix and in cervical structures 
than in the body. In the dilated cervix (ectropion) the original cylindrical epithelium may 
become stratified and converted into a tliick layer of epithelial cells (epidermidalization). 
Erosions of the cervix and of the vaginal portion may show a conversion of Epidermidaliza- 
the original cylindrical, into stratified epithelium in the course of healing; tion and the 

but the fact that the process does not extend into the deeper layers will pre- Process of 

vent an erroneous diagnosis of malignancy. In the healing process and in 
epidermidahzation we have a simple metamorphosis, while in carcinoma there is abundant 
production of epithelial masses extending into the deeper layers of the tissue. 

A knowledge of the epithelial metamorphosis that takes place in poly- 
poid proliferations in the cervix is exceedingly important; in fact, the 
importance of the epithelial changes that take place in the polypi generally is not sufficiently 
appreciated. The longer the cervical canal and the greater the protrusion 
of cervical polyps, the more intense is the metamorphosis of the cylindrical Epithelial 

epithehum. The inner surface may be covered with cylindrical epithelium Polyps, 

or very thin layers of secondarily stratified epithelium, while the outer sur- 
face already shows a thick epithelial covering in which, finally, papilla; also develop. Not only 
the surface, but the glandular formations within the polyp take part in this epithelial metamor- 
phosis. In cross-sections the picture thus produced may be difficult to distinguish from carci- 
noma, particularly if the examiner is inexperienced; onion-like formations (epithelial pearly 
bodies) may be produced by the proliferation of the epithelium, simulating cancroid. 



430 



GYNECOLOGICAL DIAGNOSIS 



Great caution is necessary in giving an opinion in regard to the malignancy of 
epithelial conditions found in cervical polyps; unless the epithelial proliferation 
extends beyond the base of the tumor, the diagnosis of carcinomatous polyp is not justified. 
Epidermidalization may be confounded with carcinomatous degeneration. In contrast to 
the genuine carcinomatous degeneration that occurs in polyps either of the body or of the 
cervix, the shape of the glaiids is preserved in the process of epidermidalization, whereas in 
carcinoma tlie degenerative process is unmistakable; the irregularities in the architecture 








Fig. 259. — Peculiar Glandular Change, partly resembling the alteration observed in pregnancy, and 
partly that of glandular cancer ; necrobiotic processes with cellular proliferation. (Original.) 

of the cells in carcinoma, in contrast to the uniform metamorphosis which takes place in 
epidermidalization, also has some diagnostic value. With a little practice it is easy to make 
a positive diagnosis, except in very rare cases, in which some doubt must always remain. 
The diagnosis between carcinomatous and non-malignant degeneration likewise presents 
great difficulties in atrophic conditions of the mucous membrane of 
the glands. Associated with metamorphosis and proliferation of the epithelium is a peculiar 
form of desquamation; the gland becomes enlarged, the tunica propria is destroyed, the 
epithelium may be preserved at certain points in the lumen, and converted into squamous 
epithelium at others; the cylindrical epithelium becomes flat, stains less intensely and, instead 
of a single layer of cells, becomes multiple (Fig. 259). The picture resembles that of the Opitz- 



SPECIAL DIAGNOSIS 



431 



Peculiar 
Behavior of 
the EpitheHura 
in Ati'ophic 
Conditions of 
the Mucous 
Membrane. 



Gebhard glands of pregnancy. As a result of various etiologic factors which cannot always 
be clearly recognized (atrophy, pregnancy, peculiar disturbances of nutrition, climacteric), 
in inflammatory processes and in passive congestion (hyperemia in polyps), peculiar but 
benign changes and proliferation of the epithelium occur in the epithehal 
structures, which may easily be mistaken for malignancy. If the inflam- 
matory irritation in the subjacent tissue (small celled infiltration of the 
tissue) is very great, the single layer of cylindrical cells on the surface may 
be converted into robust, stratified squamous epithelium without becoming 
malignant; thus, in salpingitis (Fig. 260) the surface epithelium is occasionally 
converted everyn'here into stratified squamous epithelium. The inflammatory irritation 
gives rise to a kind of stratification which may be designated psoriasis or pachydermia. 

Differential diagnosis between carcinoma and malignant syneytioma, 
and between the latter and sarcoma. Aside from the history, large syncytial masses 
point to syneytioma. The dis- 
tinction between syneytioma and 
sarcoma is somewhat more dif- 
ficult. In sarcoma, particularly 
the giant cell variety, the irregular, 
constantly changing picture of the 
cellular constituents is typical ; 
while in sync}d;ioma the picture of 
the syncytial masses and ecto- 
dermal cells is in the main uniform, 
the transition from small to large 
cells, with irregular nuclei, is char- 
acteristic of sarcoma. We no longer 
regard giant cells as belonging 
exclusively to sarcoma, since we 
know that they are also constit- 
uents of syneytioma; in them- 
selves, the giant cells do not show 
whether they are of epithelial 
(i.e., syncytial) or of connective 
tissue {i.e., sarcomatous) origin. 

There remains the differential diagnosis between carcinoma and sarcoma. In 
view of the importance and frequency of sarcomata, they will be treated in a separate chapter. 




Fig. 260. — Salpingitis ; the single layer of cylindrical cells is 
converted into stratified epithelium. (Original.) 



Sarcoma of the Uterus. 

In discussing sarcoma of the uterus it is not necessary to 
retain the strict division into the vaginal portion, cervix, and uterine 
body. Sarcoma is a malignant connective tissue neoplasm, 
while carcinoma represents a malignant epithelial growth. 
In sarcoma we have, in addition to simple numerical 
increase of the elements (hyperplasia), a change of the original type 
(atypia, heteroplasia) ; the small round or spindle cell is converted into 
elements which are larger than ordinary cells, with large 
and often irregular nucleus; the latter is often much 
larger than the original connective tissue cell. The unre- 
stricted proliferation produces at first local destruction, and later 
metastases in distant organs (heterotopia); the proliferation is not uni- 
form : large and small cells are found side by side. The change in the 



Sarcoma of 
the Uterus. 



Atypia of 

the Elements 

in Sarcoma. 



432 



GYNECOLOGICAL DL4GNOSIS 



type of the cell and the ^Yant of uniformity in their arrangement are the 
important diagnostic points. In some cases, the irregular distri- 
bution of the large nuclei produces a tigerish, spotted appearance of 
the microscopic preparation, as if a dark material had been 
dusted over it. The sarcoma usually develops uniformly and 
gradually from the connective tissue or ground substance, 
without a sharp line of separation between the normal or 
non-malignant, and the sarcomatous tissue; in carcinoma, on 
the other hand, the architecture is discontinuous, the proliferating 
epitheli'al masses appearing sharply circumscribed in the alveolar spaces. 
Depending on the variety, shape, and size of the- altered cells, 
various forms of sarcoma are distinguished. In large-cell sarcoma 
(Fig. 261) the connective tissue elements or stroma cells are converted 



In Sarcoma 
the Transition 
to (Normal) Con- 
nective Tissue 
is Gradual, 
Continuous. 




m:I'^ 



^WMk 



-y 



Fig. 261. — La.rge-cell Sarcoma; grad- 
ual transition from connective tissue to 
excessively large cells with large nuclei 
and irregular arrangement. (Original.) 







Fig. 262. — Spindle-cell Sarcoma (Myo- 
sarcoma). Metamorphosis of the narrow 
muscular elements into large, spindle-shaped 
elements with very large nuclei. (Original.) 



Large-cell 
Sarcoma. 



into excessively large round, or oval elements, with irregular outlines, 
and arranged without definite order, large and small cells lying side 
by side. The nuclei are sometimes enormous, their shape 
round or irregular; they may fill the entire cell. In the 
microscopic preparation the individual elements are in the main easily 
distinguishable by their contours. This form of sarcoma is found in 
alterations of the mucous membrane of the vaginal portion. 

Spindle- cell sarcoma (Fig. 262) usually originates in the 
cells of unstriped muscle; the connective tissue cells, or narrow 
spindie-ceii musclc fibres with rod-shaped nuclei, which sometimes 

Sarcoma. ^g^^^ ^^ rccognlzed only by their nuclei, as the cell 

body is barely visible, are converted into large spindle-shaped, long- 
oval elements; the large nucleus is oval and of variable size. 
The cells often resemble the muscle fibres of the gravid uterus. 
The muscular elements produce the impression of having become 
directly metamorphosed. The arrangement of the degenerated ele- 
ments, already distinctly sarcomatous, corresponds to that of a myoma, 



SPECIAL DIAGNOSIS 433 

with interlacing and radiating bundles (myosarcoma). If the sarco- 
matous change in the muscle fibres is associated with considerable 
proliferation of connective tissue, it is difficult to isolate large sarco- 
matous elements. The contours are not easily recognized, and the large 
irregular nuclei seen in the microscopic preparation directly indicate a 
sarcomatous change (fibrosarcoma). 

In the third variety, the giant-cell sarcoma, large polynu- 
clear cellular masses — myeloplaques — are scattered here and there 
amidst the enormous cellular proliferations. If the remain- ciant-ceii 

ing connective tissue elements are not materially enlarged, sarcoma. 

the contours of the giant-cells may be obscured, particularly if the 
section is rather thick; hence in working with this variety of sarcoma the 
sections must be made as thin as joossible. /j. 

The fourth variety, which is often Xf^i^^if-pf/"^ 

difficult to recognize, particularly if the '^*''^*'»^*2^''l-(|'!'^«f>>^''>7'j 
scrapings contain only small particles, < -■''.*'^-^*rS j% ..••. ^'. #<.r-* »V 
is the small round -cell sarcoma 
or lymphosarcoma (Fig. 263). The 
sarcomatous elements are but little ^^^f-X^^/^-t'f'^^-'r^^' 




4er. 



larger than the stroma cells, and resem- i^"^- f^fjl-z^^ — 

ble them in general appearance. The '^■''^/*J/f'^'^ 

diagnosis is based on the fact that all ^^f^'%/^ 
the sections made from the scrapings, 

_ Fig. 263. — Lymph-cell Sarcoma (small 

on repeated examination, show nothing round-ceii sarcoma). Among the individual 

. cells, which are almost uniform in size, a few 

but small round cells without a trace of larger nuclei and an occasional polynuclear 
IT T , , . , . cell are seen. (Original.) 

mucous glands. In very thin sections, 

which in this form also are particularly desirable, irregularities in the 
size of the nuclei and of the cells are also occasionally observed, and 
materially assist the diagnosis. Individual cases show a peculiar cord- 
like arrangement of the sarcomatous cells; the degenerated Lympho- 
masses are sharply separated from the surrounding tissue, sarcoma, 
and it is impossible to find any transitional forms. Within the 
interior of the cord-like masses the elements may be loosened in their 
connections, and thereby appear almost like epithelial cells. In this 
way a sarcoma may simulate an alveolar structure. 

The behavior of the glands in sarcomatous tissue is variable. 
As a rule the glands are destroyed, but they may stirvive apparently as normal glands within 
tliis sarcomatous stroma, or they become enlarged, and the epithelium is altered and becomes 
more stratified; the glands become carcinomatous, but the carcinoma is not the most impor- 
tant feature; it seems that the carcinoma "has developed against its will," if the expression 
may be iised. It plays merely a passive part. This combination is often found in the papillary 
racemose sarcoma (papilloma) of the vaginal portion or cervix, to which the term car- 
cinosarcoma lias been applied. A similar pi ctm-e is seen in a rare and most interesting 
form of sarcoma occurring in the uterine mucous membrane. The stroma tissue surrounding 
the glands undergoes a sarcomatous degeneration. The different forms of periglan- 

28 



434 



GYNECOLOGICAL DIAGNOSIS 



dular interstitial endometritis will be discussed under the head of endo- 
metritis. Periglandular interstitial endometritis gives rise to a periglandular sarcoma, part 
of the gland is surrounded by an areola of sarcomatous stroma cells, and the originally iso- 
lated areolae may gradually become confluent. The behavior of the gland cells in this form 
of sarcoma is interesting. Sometimes the epithelium is gradually destroyed, leaving a space 
filled with detritus, which may also disappear; or stratification takes place and the gland 
apparently becomes carcinomatous; but its appearance is nevertheless such as to produce 

















"r''T% ■*;"'* 



i 









, •; -:^>^ 









Vr . :;'-V . 








f'^:r% . 


% 


b 


r 

^ 


^^s^/. ,, - 



Fig. 264. — a. Periglandular Endometritis ; 6. Sarcomatous Degeneration of the Stroma Sur- 
rounding THE Uterine Glands, with preservation, atrophy, or proHferation of the glandular epithelium, 
(Section from a uterus removed on account of carcinoma.) (Original.) 

the impression that sarcomatous degeneration is the most important change present. Hence 
carcinosarcoma may occasionally be seen in the corporeal mucous membrane. This peri- 
glandular form of sarcoma resembles the so-called perithelioma, in which sarcomatous degen- 
eration occurs around the blood-vessels. 

Endothelioma. 

Endothelioma is a neoplasm originating in the endothelial cells 
of the lymph vessels; it is by some authors included among the sarco- 
mata, and often confused with genuine carcinoma — the epithelial 



SPECIAL DIAGNOSIS 



435 



Endotheliomata 

Appear 

'Worm-eaten.' 



yf^. 









#.?«;{!! #i i 









f 



• r 



neoplasm. In the uterus endotheliomata are observed in the vaginal 
portion, and especially in the cervix; they represent a form of 
degeneration and destruction which may be designated both 
clinically and microscopically ' worm-eaten. ' Clinically it 
is noted that large portions of tissue can easily be removed 
with the curette; the tissue has little resistance, and appears perforated. 
Microscopically, cylindrical (onion-like) structures in a loose retiform 
arrangement, with irregular swellings, are 
seen. Endothelioma (Fig. 265) must be 
distinguished from lymphocarcinoma in 
which the cancerous elements have sim- 
ply invaded the lymph clefts; in the 
latter the endothelium is often preserved 
above the cancer plugs. 

Endothelioma is derived from the 
endothelium of lymph vessels. The 
narrow, spindle-shaped elements lining 
the wall increase in size at the periphery 
and multiply. The lymph clefts, like the 
lymph vessels, are filled with small round- 
celled material, becoming considerably 
enlarged in places, and forming solid cords 
connected with one another by delicate 
processes. In malignant degeneration 
larger elements are produced in addition 
to the smaller cells. These have a dis- 
tinct cell body and nuclei; they become 
large, resembling squamous epithelium; 
a cavity is often produced within the 
interior of the growth, and in these cavi- 
ties the large cells are found like des- 
quamated epithelium, along with the 
parietal epithelial layer. As the cellular masses increase in size, the 
retiform, jagged appearance is lost more and more, and ultimately 
they appear like solid cancer plugs. 

In inflammatory affections the endothelial cells which line the inner 
wall of the lymph vessels, so that only the slightly protruding nucleus 
is recognizable in profile, may 'become erect'; the cells multiply and, 
with their nuclei, stand- vertically to the axis of the vessels. This gives 
them the appearance of cylindrical epithelium, and the lymph vessels 
resemble glandular canals or, as the result of proliferation, small glan- 
dular structures (Rob. Meyer: on the peritoneum). From this stage, 
which must still be regarded as benign, the malignant proliferation 



> \v.: 



^' 



Fig. 265. — Endothelioma of the 
Uterine Body. The endothelial cells as 
well as the lymph spaces are enlarged. 
The cells multiply and become as large as 
squamous epithelial cells. (Original.) 



436 



GYNECOLOGICAL DIAGNOSIS 



develops. The glandular lymph cords undergo a marked cellular multi- 
plication, the lumen becomes greatly dilated, and glandular cancer nests 
Glandular ^^^ produced. The endothelioma is converted into a lymph- 

Endotheiioma. ^-^^ glanclular carcinoma (lymphadenoma malignum, 
endothelioma gland ulare) (Fig. 266). Except that the develop- 
ment of the growth from lymph vessels can be demonstrated, the 

microscopic picture would suggest a car- 
__.''' cinoma originating from genuine glands. 

Macroscopically, glandular endothelioma looks 
like a cancer of the cervix; it is possible tliat there 
are more varieties of glandular endothehoma than 
are at present known. It is an interesting fact that 
this malignant neoplasm may occupy the deeper 
layers of tissue (as " cancer nodes ") underneath the 
weU preserved surface. 

Endothelioma occasionally occius in combina- 
tion with carcinoma. At the point where the car- 
cinoma ceases in the deeper layers of the tissue the 
picture of worm-eaten endothehoma begins. This 
term is very descriptive, but is not absolutely char- 
acteristic ; for it may occur quite independently, so 
that the endothelioma may appear both 'worm-eaten' 
and 'glandular.' 

Chondroma and chondrosarcoma 
are exceedingly rare tinnors, occurring in the vaginal 
portion or in the cervix; they may be mistaken for 
other malignant tumors. Pieces of genuine cartilage 
varying in size, and often confluent, presenting the 
picture of capsule-formation and division like normal 
cartilage, are found in tissue the seat of simple 
inflammation or true sarcomatous degeneration; in 
the latter case, the picture of chondrosarcoma 
is produced. 

Cursory reference may be made to the sec- 
ondary changes, such as myxomatous degen- 
eration, necrobiotic processes, softening and apoplexy, 
wliich occur in sarcoma as v/ell as in carcinoma. 




% 



^-9 






® 

Fig. 266. — Glandular Endothelioma. 
The endothelial cells are enlarged and become 
irregular ; they multiply like epithelium, 
with the production of stratified glandular 
formations. (Original.) 

The lipomata and osseous, fatty, and glandular 
formations occasionally observed in the uterus and in myomata do not belong in tliis chapter, 
which deals solely with the microscopic diagnosis of the malignant diseases of the uterus. 



Malignant Degeneration of the Vagina and Vulva. 

As in diseases of the uterus, the two important changes in these 
structures are cancer and sarcoma. Tuberculous affections will be 
mentioned briefly in connection with the differential diagnosis. It is 
not so difficult to recognize malignant degeneration in the vagina and 
vulva as in the upper portions of the genitalia, because more assistance 
is obtained from inspection and palpation; hence microscopic exami- 
nation is required practically only for confirmation and decides the 



SPECIAL DIAGNOSIS 



437 



diagnosis only in doubtful affections. The nature of an ulcer in the 
vagina or on the vulva may occasionally be doubtful — whether simple 
inflammatorj^, tuberculous, specific, carcinomatous, or sarcomatous. 
Varicose formations (after the prolonged use 
of pessaries), associated with hemorrhage 
and ulceration, or without these complica- 
tions, may raise the question of innocence or 
malignancy. It may be asked whether a 
rodent ulcer, clinically diagnosed as such, 
is carcinomatous or not; simple decubital 
ulcers often have a suspicious look. In the 
microscopic picture of an excised portion 
of the growth, carcinoma is recognized 
by the epithelial plugs which begin in the 
surface and continue to grow down into 
the deeper layers; while inflammatory 
ulcers merely show small-cell infiltration, 
and tuberculous changes are identified by the finding of tubercle 
bacilli and giant cells, regarded by many as specific constituents of 
tubercle; the nuclei in the giant cells are usually arranged eccentrically 







Fig. 267. — Hidroadenoma Sub- 
CUTANEDM (in part diagrammatic). 
(Original.) 




'■'*- i 



Fig. 268. — Hidroadenoma Poltposum (in part diagrammatic). (Original.) 



or peripherally, in circular or crescentic lines. With regard to the diag- 
nostic significance of spirochaste pallida in doubtful ulcerations of 
the vaginal portion, we have as yet no observations. 

Sarcomatous degeneration, which is rarely seen in the vulva, 
but more often in the vagina, is recognized by the excessive prolifer- 



438 



GYNECOLOGICAL DIAGNOSIS 



ation of the cells and their atypical architecture (see above). Carci- 
noma of the vulva and of the vagina is usually of the simple alveolar 
type (solid plugs), or of the cancroid variety (epithelial pearly bodies). 






m- 






Another form of carcinoma that occiirs in the violva is that which originates from 
sebaceous glands, the histologic picture of which is easily recognized. The hidro- 
adenomata which occasionally occur in the vulva and which have been described by 
Gebhard, Pick and Hermann Ruge, present some difficulties in regard to their origin, and also 
as to the question of malignancy. They are supposed to originate in the sweat glands of the 
vulva, and their structure often suggests that of malignant adenoma. The epithehum often 
consists of^ only two layers, but under the influence of marked metaplasia stratification and 
solid epithelial plugs may develop and produce a cancerous appearance. These, or similar 
structures apparently originating in the same matrix, are situated underneath the surface of 
the vulva, which is often intact, and are about as large as a small iDcan (Fig. 267); or they 

may be pedunculated (polypoid. Fig. 268); or attached 
to the skin like fungous growtlos (Fig. 269). There is 
much to indicate that these structures originate in the 
sebaceous glands; in spite of their cancerous structure, 
they cannot be included among malignant neoplasms, 
except in rare instances. Many epithelial changes occur- 
ring in polypoid prohferations, the Opitz-Gebhard glands, 
are not malignant in spite of their appearance, just as 
there are physiologic prototj'pes of carcinoma — as the 
decidual cell is the physiologic prototype of sarcoma. 
Carcinoma of Bartholin's gland may have 
a glandular structiire, thereby differing from carcinoma 
of the vulva and vagina. Finally, the so-caUed vaginal 
adenoma remains to be mentioned. Glandular pro- 
liferations occur underneath the epithelium, with large 
and small cavities lined with a single layer of epithelium 
of the cervical type. In one case — a tumor the size of 
a plum at the introitus — the tumor reciu-red, although the microscopic picture was not malig- 
nant; the recurrence was apparently a simple secondary proliferation. In another case, in 
which the tumor larger than the fist, was situated higher up, it resembled an adenomyoma, the 
simple, large and small glands being surrounded by muscular layers (Rob. Meyer-Weidling). 





Fig. 269. — Hidroadenom.a. Fdn- 
GOSUM. The origia of these three 
forms still remains to be determined 
by more detailed investigation. (In 
part diagrammatic.) (Original.) 



SPECIAL DIAGNOSIS 439 



Microscopic Diagnosis of Polyps and Tissue Frag= 

ments from the Genitalia. 

(Myoma, Myosarcoma, Mucous Polyps.) 

The following discussion will include material removed by opera- 
tion as well as such as is expelled spontaneously. Diagnosis, prognosis 
and treatment depend on the nature of such material as determined 
by post-operative examination. For example, if a piece of tissue is 
shown to be malignant, or the base of a polyp exhibits carcinomatous 
degeneration, total extirpation will be performed. With a little prac- 
tice the examiner will be able to make the diagnosis in many cases 
by a careful naked-eye inspection, but very often a microscopic 
examination is indispensable and should therefore never be omitted. 

Organized or unorganized benign or malignant masses, products 
of pregnancy, may be expelled or removed from the uterus. 

Unorganized membranous structures have already been described 
in detail and I shall here discuss the more solid, clumpy masses 
or fragments, which include the large calcareous or stony concretions 
that are expelled spontaneously or have to be removed by unorganized 
artificial means. These masses are derived from necrotic Masses, 

proliferations impregnated with shreds of calcium (polyps, polypoid 
myomata), or blood clots which have attached themselves in layers to 
placental remains. After treatment with nitric or picric acid the origi- 
nal, partially organized tissue can be recognized (connective tissue, 
muscle and fibrin). Occasionally foreign bodies are found free within 
the uterus and attest the great tolerance which the organ sometimes 
has for its contents. 

Organized membranous structures have also been dis- 
cussed in a former chapter. For the most part they represent changes 
due to pregnancy, although occasionally they occur independently of 
gestation. In addition to these, more compact, firm and organized 

even polypoid masses are observed which owe their origin structures. 

to the products of conception. In these masses, which sometimes 
attain the size of a small apple, the villi may be visible to the naked eye 
and permit a diagnosis of previous pregnancy. They are the so-called 
placental polyps. The shape of these polyps may be placental 

either round or oval. The surface is smooth, rarely rough; Polyps 

the cross section not infrequently suggests the laminated arrangement 
seen in thrombi. The centre of these structures is formed by a vascular 
villous tissue. 



440 GYNECOLOGICAL DIAGNOSIS 

Macroscopic examination may not suffice, particularly as a villous 

appearance is very apt to lead to a false diagnosis; hence in difficult 

cases the microscopic demonstration of villi and the finding of decidual 

remains, usually in a state of advanced fatty degeneration, 

Deception . . t, i , . , „ , . 

Due to Villous are decisive. With the aid of the microscope it is also 
possible to determine, by the appearance of the villous 
plugs (epithelial processes) and possibly by the presence of the layer of 
Langhans, the period of gestation to which the structures belong. 
'Villous' masses, shaggy, gangrenous fragments of myomata may 
simulate chorionic villi; blood clots may take the form of a villous 
ramification instead of a solid lump, an anomaly which has led to false 
diagnosis both by macroscopic and by microscopic examination. A 
number of malignant tumors may be shaggy or villous. The products 
of conception also include the small cysts or berries that are occasion- 
ally presented for examination and which owe their origin to hydatid 
cysts; their discharge is accompanied by severe hemorrhage. 

A large share of the material derived from the uterus — usually 
removed by operation — is supplied by A. myomata (myomatous 
Myomataand potyps) and B. mucous polyps. Myomata may 
Mucous Polyps. fQj.j^ whcrcver there is muscle, hence also in the cervix, 
although less frequently than in the body. Mucous polyps occur in any 
part of the uterus that is covered with mucous membrane. 

A. Myomata may be observed in the form of myomatous 
polyps. They may have a moderately thick pedicle (myoma pen- 
dulans) or be attached to the uterus by a broad base. Pendulous 
myomatous polyps with a moderately thick stalk are usually edematous 
and may exhibit either true myoma-formation or only contain a certain 
quantity of muscular tissue; they are usually covered with atrophic 
mucous membrane, while in the body of the uterus considerable 
hyperplasia of the mucous membrane may, and in the case of 
myomata usually does take place. 

The more muscular, pedunculated polyps which, even if 
they contain but little muscle, should be designated fibro- 
muscular (fibrous) polyps, may attain the size of a plum and are 
Myomatous sometimcs very vascular. The muscular tissue which 
Polyps. enters with the pedicle spreads out, and the individual 

bundles become gradually thinner, forming a slightly radiating, diffuse 
arrangement. Under the atrophic mucous membrane are numerous 
fibrous masses which push their way in between the strands of muscle- 
fibres in the pedicle. These muscular or fibromuscular pedunculated 
polyps may be the seat of benign or malignant degeneration. 
Sometimes the mucous membrane alone, particularly the glands, may 
show a variable degree of hypertrophy: the polyp becomes glandular 



SPECIAL DIAGNOSIS 441 

(polypus muscularis and fibromuscularis glandularis); 
the glands retain the epithelium which covers the seat of their origin, 
whether corporeal or cervical. Or, carcinomatous or sarcomatous 
degeneration may occur: the carcinoma begins in the surface (in the 
mucous glands) or in the glands which have penetrated the polyp. 
The cancer is usually alveolar, with the formation of solid epithelial 
plugs. Malignant adenomatous proliferations may also occur. 

As a rule the pedicle is free, and removal of the polyp is equivalent 
to radical removal of the carcinoma; at the base there may be normal 
glands free from malignant degeneration. Within th'e polyps there is often 
found a combination of carcinoma and sarcoma; 
the sarcoma cells are usually of the large cell variety, '^"s^rcomaand 
with large, well staining nuclei; the sarcomatous masses ^'^""p^yp" 
are disseminated throughout the polyps. It appears that 
sarcomatous degeneration is prone to develop in polypoid proliferations 
whenever some nutritional disturbance (stasis, insufficient nutrition 
when the pedicle is thin) is combined with irritation. The first variety 
of polyps, which shows true myomatous development (myoma poly- 
posum), presents on the cut surface, in addition to atrophy of the 
mucous membrane, the firm, hard, glistening structure of myoma, 
usually circumscribed and containing a network of glistening bands of 
muscle tissue which are often likened to asbestos, and which represent 
longitudinal, transverse and oblique sections of the muscular or fibro- 
muscular proliferations. The asbestos appearance is most marked in 
the longitudinal bundles. Polypoid myomata are usually spherical or 
flattened (almond-shaped). 

Uterine myomata are very broadly sessile and situated either 
underneath the mucous membrane or at a variable depth in the uterine 
muscle. The cut surface presents the appearance already described; 
firm, hard and whitish when there is much connective uterine 

tissue, more grayish or grayish-red and softer when the Myomata. 

muscular tissue preponderates. The tumor is called myoma, myo- 
fibroma or fibromyoma (uterine fibroid), depending on the propor- 
tion of connective tissue present. In the largest myomata, 
such as are usually obtained by operation, two features of Myofibroma,' 
special interest are observed. First, the stratified muscular i romyoma. 
layer which seems to peel off in layers which surrounds the myoma, and 
second, the distinctly lobular structure of the tumor. At the periph- 
ery particularly, spindle-shaped and cylindrical segments of varying 
sizes can be separated from the main tumor. While at the centre of 
the tumor this is not possible, one nevertheless gets the impression 
that the individual nodes of myomatous tissue were originally loosely 
connected and that their solid consistency is the result of adhesions. 



442 GYNECOLOGICAL DIAGNOSIS 

This peculiar structure is explained by the mode of growth — by appo- 
sition— t.e., the original myoma at the centre grows by the constant 
addition to its periphery of large and small, newly-formed myomata. 

In the layers of muscular tissue which form around the 
GrowtT^th myoma, enlargements ranging from the size of a lentil to 
Proliferation. ^^^^^ '^^ ^ beau are seen, which resemble nerve ganglia; at 

first these enlargements are connected with the myoma by 
delicate fibres, which in time become shorter and thicker, until finally 
the enlargements are in close contact with the tumor. By virtue of the 
lamellar formations in the surrounding muscle, which produce muscJe- 
rhomboids as in the case of the gravid uterus, the myoma can be 
"enucleated." In the small, subniiliary swellings of the muscular 
lamelhr, which gradually become larger and are converted into myomata, 
the first microscopic change is small cell proliferations (granulation 
tissue), from which the muscular and connective tissue portions ulti- 
mately develop. Various changes, both benign and malignant, occur 
in myomata; sometimes they are distinctly seen with the naked eye, 
but often they can be discovered only with the microscope. 

The most important of the benign changes is glandular degen- 
eration. The glands in the mucous membrane proliferate and pene- 
trate the myoma. Glandular degeneration (adenomyoma) may 

lead to the production of large structures or cysts the size 

Benign ^ ° -^ 

Metamorphosis of a plgeou's cgg; every gland duct or gland tube (body) 

of Myomata. , ... 

that penetrates the myomatous tissue may m turn give 
rise to fresh glandular proliferations; small glandular depressions are 
even found in deep-seated myomata. Considerable differences may be 
observed in myomata that are situated side by side; some may be free 
from glands while others are the seat of glandular degeneration. The 
glandular wall is covered with the epithelium of its site of origin, i.e., 
corporeal epithelium, if the gland originates in the corporeal mucous 
membrane; the epithelium is often distinctly ciliated. The character 
of the epithelium decides whether a cyst or an apparently glandular 
space is really a gland or the result of breaking down of the tissue, or 
whether the cysts are derived from lymph clefts. Necrosis (necro- 
biotic processes) is another benign change that is frequently observed. 
Portions of the tumor or the entire myoma may be completely devoured 
by necrosis. The necrotic portions are discolored and often separated 
from the rest of the tumor by a sharp or indented boundary line. In the 
microscopic picture all that finally takes the stain is a few blood-vessels; 
the rest is diffuse, fibrous, and no longer capable of staining. Necrotic 
portions may be reddish — claret color — or quite yellow or whitish; the 
microscopic picture does not show true "fat, " but rather a fine granular 
mass, edematous infiltration of the dead tissue. 



SPECIAL DIAGNOSIS 443 

Calcification, with the production of a whitish, friable mass 
(carbonate and phosphate of calcium) often occurs. The calcium salts 
are precipitated in the necrotic portions of the tissue. 

. . . Calcification. 

Direct metamorphosis (a) into osseous tissue not 
infrequently occurs. After removal of the calcium salts with picric or 
nitric acid the characteristic picture of bone corpuscles and their 
processes and Haversian canals is seen under the micro- Bone-formation 
scope; the bone tissue may be isolated within the tissue, mMyomata. 
or calcified portions of the tumor may be found in the neighborhood. 
(b) The occurrence of genuine fatty tissue is also interesting. 
A large myoma may contain enormous islands of fat, containing 
genuine yellow fat-cells. 

The most important, as well as the most frequent among malig- 
nant changes is sarcomatous degeneration. The entire myoma 
is rarely attacked at once, the affected portions sometimes being 
widely separated by healthy tissue. Sarcomatous degeneration 
may be suspected by the naked-eye appearance alone. The 
originally whitish tissue, which shines like asbestos and shows 
transverse and longitudinal layers from the interlacing or rhomboid 
fibres, in the cut surface appears slightly elevated above 

^ . . . Sarcomatous 

the surrounding level; tne tissue is uniformly velvety, and Degeneration 
the color a uniform, soft gray. Under the microscope the 
individual radiating and interlacing strands of muscle-tissue are seen 
within the fibrous structure. The deviation from the normal type seen 
in the nuclei is very conspicuous. The narrow, rod-shaped nuclei, which 
merely suggest the cell body of the muscle-cells without bringing out 
their contours distinctly, become large and finally excessively large, 
broad and oval; the arrangement is irregular and the nuclei are very 
variable in size. Gradually an atypical, excessive growth spindie-ceii 

is seen, in addition to the spindle-shaped enlargement of sarcoma, 

the elements — spindle-cell sarcoma. — Another variety is the 
large round cell sarcoma. The large nuclei are often irregular 
both in shape and arrangement and look like macules Large Round 
among the smaller nuclei. The picture is irregularly Ceii sarcoma, 
strewn with dark granules. In favorable specimens the gradual 
transition from the normal to the sarcomatous elements can be 
seen. Sarcomatous degeneration of myomata is equivalent to the 
sarcomatous change in the glands which proliferate into the myoma 
(carcinomatous alteration of adenomyomata). It is possible, although 
rare, for carcinomatous degeneration in the neighborhood to penetrate 
into a myoma. 

The pathologist is occasionally requested to examine cylindrical, 
solid, dark red, or circular masses which suggest polypoid or myomatous 



444 GYNECOLOGICAL DLA.GNOSIS 

material. These masses are expelled spontaneously or appear during 
labor along with the child's head; or they are removed from the 
anterior or posterior lip of the cervix. By careful macroscopic exami- 
Cervicai nation these solid masses can be identified as parts of the 

Tissue. cervix (vaginal portion). They present an outer sur- 

face covered with squamous epithelium and an inner surface showing 
the cervical folds. If the partially separated lip remains in situ for 
some time after labor and retains its connection with the cervix, a change 
in the shape of the epithelium takes place and a detailed microscopic 
examination is necessary to identify the tissue. 

B. With regard to mucous polyps, they have the same com- 
position as the soil from which they spring. Stroma and parenchyma 
are the same, and the proportions only are changed. Mucous polyps 
Mucous may be glandular or interstitial whether they originate in 

Polyps. ^]^g body, the cervix or the vaginal portion; if glands are 

practically absent, a fibrous polyp results. With regard to nomen- 
clature, the term cervical or corporeal, glandular or fibrous polyp is 

to be preferred to adenoma. Cervical adenoma and cor- 
SfypPref- poreal adenoma are also used to designate either circum- 
Adeioma scHbcd (polypoid), or diffuse glandular proHferation of 

the mucous membrane. Adenoma means a gland tumor; 
hence a fibrous polyp would be a gland tumor without glands or con- 
taining very few glands. The term adenoma has no advantage over 
polyp, to which we have become so accustomed that we are no longer 
disturbed by its derivation ('supplied with many feet'). On the other 
hand, we have also become accustomed to associating the idea of 
malignancy with the term adenoma. 

Polyps of the corporeal mucous membrane may be 
glandular. The glands may be dilated or cystic; like the surface 
they are covered with a single layer of cylindrical epithelium. In large 
Glandular cystic dilatatious the epithelium is more cuboidal and of 

Polyps. -j-^g corporeal type; the protoplasm stains well and the 

nuclei are central. The glands in the polyps may increase by divi- 
sion, or new glands may be formed by dipping down of the surface 
epithelium. When the glands are but little involved, fibrous polyps 
are produced — p o 1 y p u s m u c o s u s corporis i n t e r s t i t i a 1 i s 
(glandularis). Extensive, broadly sessile prohferations, which to 

the naked eye often present an appearance similar to that 

Epidermidali- . titi 

zation of of frog-spawn, owing to slight dilatation oi the glands, are 

• ' designated molluscum. Alterations may take place 

in corporeal polyps by a simple increase in the layers of epithelium at 
the surface; one side of the polyp only is usually affected and the 
process, which is on the whole rare, is of no special significance. 



5Vr^:.i7 



SPECIAL DIAGNOSIS 445 

Ordinary epidermalization and modifications of the pictures of 
polyps may result from marked increase of the blood-vessels and hem- 
orrhages. Malignant degeneration is on the whole rare. In carci- 
noma the epithelium becomes stratified and proliferates; 
the picture is usually that of alveolar carcinoma, but DegeneStton 
malignant adenomyoma also occurs. Sarcomatous p^,j "sis^Rare 
degeneration is even rarer than carcinoma in mucous 
polyps; but the alteration is common in processes associated with great 
nutritional disturbances (stasis, pressure), as, for example, pyometra. 

Mucous polyps of the cervix hke those of the body may 
be either glandular or fibrous (interstitial). Constriction of the glands 
occurs much more frequently than 
in the corporeal polyps, and the 
cystic dilatations are greater. The 
epithelium in the glands is of the 
tall cylindrical type, in the dilated 
portions somewhat shorter; the 
cell body does not stain and the 

nuclei are basally situated. The ':;'-.-;' ,"' 

same elevations which are seen in . ' . "■''ifi^^rii'^' --^ 

the cervical glands and which in ^,\ ■ y-'^ ,\'--. , - 

transverse sections look like papillae 
may occur in polyps. Conversion 
of the surface epithelium into a ^i°- 270.— fragments from the bladder: 

papilloma of the bladder. So far as the stroma 
stratified epithelial layer is much can be seen, it contains no cancerous invasion 
. (suspicious case). (Original.) 

more common than m the case or 

corporeal polyps; the stratified epithelium projects into the glands, or 
even to a considerable depth into the substance of the polyp. If the 
cervix becomes greatly dilated or the cervical polyp emerges from the 
dilated os epithehal pearly bodies, onion-like structures, 
which are very apt to suggest malignancy, may develop in 
the epithelium. In transverse and oblique sections the pictures are very 
often suspicious, the tissue appears to contain 'cancer nests' and 'cancer 
plugs.' Malignant degeneration is rare in polyps, and if epithe- 
lial changes are present, great caution must be observed in ^ , 

. . . . . Epidermidali- 

giving an opinion on the microscopic picture. As already zatiou of 

emphasized, the structure of the base must be particularly 
investigated in the case of polyps. The surface of cervical polyps, like 
the mucous membrane of the cervix itself, may be the seat of papillary 
proliferation (corresponding to papillary erosion). New forms of cervical 
glands may also result from dipping down of the surface epithelium. 
Polypoid proliferations whichoccurinthe vaginal portion 
should not be designated mucous polyps. They originate in the erosion 



446 



GYNECOLOGICAL DIAGNOSIS 



glands, which are constricted off by the epidermidalization, become 
enlarged from the accumulation of mucus, and finally converted into 
'folhcles' (ovula Nabothi). By proHferation so-called follicular 
polyps may be formed; cervical polyps often develop in the same 
manner. No noteworthy changes require mention. In the vaginal 






Fig. 272. — Ureter: 
stratified epithelium. 
(Original.) 




Fig. 271. — Fallopian 
Tube: single layer of 
cylindrical epithelium. 
(Original.) 



portion hard, villous, polypoid structures are occasionally found, cov- 
ered on the outer surface with the stratified epithelium of the vaginal 
portion, and occasionally with cervical epithelium on the inner surface; 
but the stroma of these structures is exactly like that of the portio 
vaginahs. The formation of these structures must be attributed to 
ulceration of one lip, or a large portion of one lip, during labor (see 




Fig. 273. — VERMypoRM Appendix; fecal remains, glands, follicles. (Original.) 

above). The racemose polypoid proliferation — exceedingly malignant 
sarcomatous changes (cauliflower-tumors) — have already been discussed 
in connection with cancer (see above). 

Urethral polyps often have a very thick epithelial layer with crypt-like depres- 
sions; in the microscopic picture they are apt to arouse the suspicion of cancerous degen- 
eration. As a rule the stratified epithelium is covered with a layer of cylindrical cells (comp. 
Fig. 59). As in the case of polyps, the greatest caution is necessary in making a diagnosis. 



SPECIAL DIAGNOSIS 447 

So-called urethral fungus, which is often submitted for an opinion, usually con- 
tains granulation-tissue, rather dilated vessels and a thin laj^er of epithelium. Fragments 
of tissue from the bladder may be quite difficult to interpret (Fig. 270). 
Papillary proliferations (papilloma vesiculae u r i n a r i ae) may be Tissue Frag- 

submitted for an opinion which are covered with unusually thick epithe- the Bladder. 

lium or possess only a single coimective tissue stalk. As only a small quan- 
tity of material is usually available, it is often very difficult to decide whether the epithelial 
proliferation is extending progressively into the deeper layers of the tissue, in other words, 
whether carcinoma is present. 

Occasionally certain other peculiar things, derived from the genitalia or said to be 
derived from the genitalia (^^arious foreign bodies), are submitted for examination. Para- 
sites (oxyuris) occasionally get into the genitalia. I shall not discuss these things here, inter- 
esting though they sometimes are. A question which the examiner is occasionally asked is 
whether certain cord-like, firm, whitish particles which are found in extirpated myomata or 
uteri are ureter, vermiform appendix or Fallopian tube. The pieces are often so small tliat 
the decision cannot be made with the naked 

eye. The tube (Fig. 271) is lined with a single . '~\ 7' ,". 

layer of cylindrical epithelium, differing from , ' : .\ ) 

the ureter (Fig. 272), which has stratified // ;| ^'^ 

.squamous epithelium; some differences in the 
arrangement of the muscle fibres are also 
observed. The vermiform appendix 
(Fig. 273) may be identified by fecal contents 
and by the glands and follicular structures con- 
tained in the mucous membrane. Small pieces 
of uterine muscle, which may be often included 
in a specimen obtained from a greatly altered 
and adherent tube, are recognized by the 
picture of the muscular fibres and by their 
arrangement. It is important to subject fig. 274.— Nasal Polyp: greatly thickened, 

everything that is expelled from the uterus stratified, squamous epithelium with gland-like 
, ~ -1 . 1 ■ J c 4.U i i invaginations in the greatly inflamed and irritated 

and everythmg derived from the uterus to ^5^^^° (Original.) 

careful macroscopic inspection and, if there 

is the slightest dotibt, the tissue must also be examined under the microscope. The expert 

wiU usually be able to interpret with the naked eye tilings which a less practiced examiner 

will find difficulty in recognizing even with the aid of the microscope. 

In connection with myomatous and polypoid masses mention 
should be made of the fragments of tissue which sometimes adhere to 
the examiner's finger and the study of which is often very important. 
Careful microscopic examination in the recent state or Tissue Frag- 
after embedding the material may prevent serious errors. a™thrcun^°^ 
The diagnosis made with the finger during examination, Examination. 
e.g., the diagnosis of abortion, may prove to be erroneous. In beginning 
carcinoma, which is situated at the internal os and immediately above 
that point, the most experienced clinician may make a mistake in 
diagnosis unless a microscopic examination is made of the particles of 
tissue that adhere to the finger. 

There is one mistake — that of basing one's judgment on individual 
cells — which must be carefully avoided. There are no specific elements 
that indicate cancer with absolute certaint}^ The bladder cells are the 
physiologic prototypes of carcinoma, as the decidual cells are the proto- 




448 GYNECOLOGICAL DL\GNOSIS 

types of sarcoma. In very rare cases certain conclusions may be drawn 

from solitary epithelial cells (supported by clinical observation), if, for 

example, material without any other foreign admixture is 

A Microscopic . ..,.,, 

Diagnosis Based obtained from the cervix m which large epithelial struc- 

on Individual -ii iii i- r-ii 

Cells is De- tures With abnormally large nuclei are found — elements 

cap ive. which clo not occur in this situation under other circum- 

stances. Not only the elements of malignant tumors have their physio- 
logic prototypes and are therefore not in themselves characteristic, the 
Bladder Cells structurc of malignant neoplasms also has its prototype, 
and Decidual The iiiucous membrane of the tube (see above) in its abdom- 

Cells are the 

Prototypes of inal poi'tioii closely resembles malignant adenoma and might 

Carcinoma , . , „ • -r> • i 

and Sarcoma be mistaken for a metastasis, iienign changes m certain 
especivey. portions rescmble the malignant neoplasms that occur else- 
where: the picture of an ovarian cyst resembles that of glandular cancer 
elsewhere. Changes of the nasal mucous membrane (nasal polyp. Fig. 
274), iudgecl by their structure alone, might be mistaken 

Physiologic /; J to J _ ^ ) o 

Prototype of for carclnoma if found m other situations, and the same 
might be said of papillary changes in the urethra. Hence 
the study of diagnosis must include not only the study of the normal 
composition of tissues, but also a knowledge of the changes that occur 
in different situations. Malignant degenerations vary in their appearance 
and form according to the organ that is attacked. 



SPECIAL DIAGNOSIS 449 



Diagnosis of Tubal Diseases. 

The most important among the diseases of the tubes are the inflam- 
matory diseases, which are all due to infection. The structures are invaded 
by microorganisms from without, usually from the uterine cavity, more 
rarely the abdominal cavity; these lodge in the folds of the 

, , , . , . , Definition. 

mucous membrane and produce a reaction which extends 
to the muscularis and the serous coat. The inflammatory products at 
the same time are deposited in the interior of the tube and, when 
the abdominal extremity closes up, accumulate and cause distention. 

Depending on the kind of microorganisms, the degree and extent 
of the tissue reaction, and the age of the process a variety of clinical 
pictures are produced. As these frequently represent only different 
stages of the same disease, the development of one form from another 
can be directly seen if the patient is long enough under observation. 
For example, a recent gonorrheal infection of the tube produces a puru- 
lent salpingitis; as the accumulation of pus which results from closure 
of the abdominal extremity becomes more abundant, a pyosalpinx 
develops, and in the course of years, as the tissue reaction subsides and 
the pus becomes absorbed, a hydrosalpinx results. The disease may 
require medical intervention at any stage, and it is therefore necessary 
to resolve inflammatory tubal diseases into the individual clinical 
pictures which the physician is called upon to diagnosticate. 

Inflammatory disease of the tubes occurs in the following forms: 

Salpingitis. 

Anatomic Picture. In catarrhal salpingitis the mucous mem- 
brane is swollen and the lumen of the tube is filled by its thickened 
folds. The muscularis is moderately infiltrated and only 

Til 1 • ^ ^ mi i ii-l • Salpingitis. 

slightly thickened. ihrough the abdominal extremity 
the inflammation extends to the adjoining pelvic peritoneum and the 
serous covering of the tube itself, and produces adhesions between the 
abdominal extremity and the adjacent organs. The lumen contains 
moderate quantities of serous fluid. In purulent salpingitis the 
inflammatory processes are increased in severity. The swelling of the 
mucous membrane is much greater, and ulcers are sometimes present. 
The muscularis is extensively infiltrated and often as thick as the thumb. 
The infection travels from the tubal wall and out b}^ the abdominal 
extremity to reach the serous covering of the tube, as well as the pelvic 
peritoneum, and leads to occlusion of the fimbriae and adhesions with 
29 



450 GYNECOLOGICAL DIAGNOSIS 

the organs that are in contact with the infected areas. In this wa^* the 
tube' becomes adherent to the omentum, intestines, bladder, uterus, 
and particularly the pelvic wall around the fimbriii?. Not infrequently 
the inflammation penetrates the connective tissue surrounding the tube 
and produces a circumscribed thickening. The lumen usually con- 
tains some pus, which may be serous, cheesj^, granular or inspissated. 
In this way the normal tube becomes thickened and forms a cord 
which follows the normal course of the tube from the cornu of the uterus 
in a convex line downward and backward. 

Diagnosis. While palpation of "the normal tube is ver}' difficult 
and possible onh'- under favorable conditions of the abdominal walls, 
diseased tubes, owing to the thickening of their walls, are quite easy 
Palpation of to fccl. The examining hand is pressed firmly against the 
the Tubes. internal hand, so that the palpating fingers come in contact 

alongside of the uterus, and are moved up and down in a direction 
perpendicular to the course of the tube, when a cord of varying thick- 
ness will be felt rolling between the fingers. If the tube is verj" near the 
anterior pelvic wall, it may be difficult to bring the fingers together at 
that point; but if the uterus is elevated with the internal hand, thus 
bringing the tube nearer the abdominal wall, it will be felt with the exter- 
nal hand as a transverse cord immediately underneath the abdominal 
walls. In searching for the tube the hands must be kept near the cornu 
of the uterus because the tubes are hardest at that point, whereas near 
the abdominal extremity the cord is softer and its shape more indefinite; 
occasionallj' palpation of the uterine portion may be rendered easier by 
rolling it back and forth on the lateral aspect of the uterus as a base. 

The palpatory- findings in salpingitis vary, depending on 
whether the process is quite acute, or secondary' changes resulting from 
inflammations are present. In acute conditions, owing to the greater 
tenderness of the tube and the peritoneal involvement, it is usuall}' 
impossible to feel the tube itself, and the examiner must be content 
with localized tenderness in the tubal region; or possibly an indefinite, 
soft consistency with indefinable limits maj^ be recognized. Hence the 
diagnosis in this stage is usuall}^ uncertain. After a certain interval, 
usuall}' a few days, the tubes themselves can be felt and the inflam- 
matorj^ changes can be demonstrated b}' palpation. The changes vary 
according to the intensitj' of the inflammatory reaction. 

In the mildest forms of catarrhal salpingitis the tube is but 
slightly thickened, often merely a little harder than a normal tube and 
somewhat painful on pressure. In chronic cases pain, occurring only 
at the instant when the tube is engaged between the palpatory 
fingers, is the only demonstrable sign. The greater the inflammatory 
reaction in the wall, the thicker and harder will be the cords. The 



SPECIAL DIAGNOSIS 451 

ovary may be found isolated in the arch formed by the tube or close 
to the abdominal extremity (Fig. 275). Adhesions are sometimes 
absent altogether or may be few in number and soft. 




Fig. 275. — Catarrhal Salpingitis. P.-F. H- (Original.) The left, tube contains a nodular swelling; 
both ovaries can be outlined ; no adhesions. 

In purulent salpingitis the objective changes are much more 
pronounced and the diagnosis is accordingly much easier. The tube, 
which is often as thick as the finger, is readily identified by its arching 




Fig. 276. — PiTrulent Salpingitis. P.-F. %. (Original.) Right tube very tortuous ; left tube drawn 
out and surrounded by adhesions at its abdominal e.xtremity. 

and slightly tortuous course. It is always easiest to feel the uterine 
portion of the tube, which begins at the cornu, because it is broad and 
thick and occasionally contains a few nodules; while the lateral portion, 
being filled with secretion and adherent to the pelvic wall and the 
ovary, is much less distinctly felt (Fig. 276). The consistency of the 



452 GYNECOLOGICAL DIAGNOSIS 

tube IS very hard and firm, and tenderness is rarely wanting, but 
depends in the main on the character of the accompanying inflammation. 
The outer convex outline is usually much more distinctly palpable than 
Purulent the luuer, concave border toward the uterus, because the 

Salpingitis. inflammation often extends from this point to the broad 

ligament, obscuring the latter, and also on account of the numerous 
adhesions with the uterus. The ovary can rarely be felt separately, 
but its position may be inferred if an isolated tumor is outlined along- 
side of the abdominal extremity of the tube. The diagnosis of tubal 
disease is rendered much more difficult by certain displacements of the 
uterus. In retroposition, for example, the fundus and tubes are placed 
so far backward that it is verv difficult to differentiate them. Examina- 




FiG. 277. — Double Ptosaxpinx in Retroversion of the Uterus. P.-F. 3-3. (Original.) 

tion under anesthesia is often required. In retroversion and retro- 
flexion it is almost never possible to feel every portion of the tube; 
the uterine portion, which is diagnostically most important, can be 
reached only by forcibly elevating the posterior vaginal vault. On the 
other hand, the club-shaped extremity, which is directed forward, 
can often be felt quite easily (Fig. 277). It ma}" be possible by means of 
a rectal examination to recognize the tubal disease when the uterus is 
in retroflexion. Occasionally in retroversion only a part of the thick- 
ened tube is felt alongside of the uterus and identified as the tube by 
its cylindrical, finger-like shape. 

Differential Diagnosis. If the swelling of the tube is at all distinct, 
it is hardly possible to mistake the diagnosis of salpingitis. The normal 
ovarj" must not be mistaken for the abdominal extremity of a thick- 
ened tube. If the ovary is spindle-shaped and gradually merges with 
the ovarian ligament, it may resemble a tube very closely; but as the 



SPECIAL DIAGNOSIS 



453 



latter is inserted high up at the fundus, while the ovarian ligament is 
much lower down, the point of insertion can be determined by careful 
examination of the lateral aspect of the uterus; or the uterine portion 
of the tube, in which the changes are most distinct in every form of 
tubal disease, may be investigated. 

Parametritic and perimetritic adhesions rarely give 
rise to errors, because diseased tubes are thicker and more round than 
adhesions and because the latter are usually multiple and do not present 
the characteristic course of the Fallopian tubes. Accumulations of 








Fig. 278. — Various Forms of Retention Tumors of the Fallopian Tube. J^. (From specimens in the 
Kgl. Universitiits-Frauenklinik in Berlin.) 

scybala in the sigmoid flexure, and sometimes even the empty gut, 
may be mistaken for a thickened tube on the left side, because the rows 
of scybala may simulate tortuosity and may occupy the situation of the 
tube. The sigmoid flexure, however, owing to the length of its mesen- 
tery, is always more movable than the tube; it is sometimes placed in 
front of the uterus; and the scybala, unless they are too hard, can be 
compressed and are not painful. Finally, the diagnosis can be assured by 
repeated examination, particularly after laxatives have been administered. 



Retention Tumors. 

When the abdominal extremity of the tube is occluded by peri- 
salpingitic inflammation and the mucous membrane secretes inflam- 
matory products, the latter' accumulate in the lumen and distend the 



454 



GYNECOLOGICAL DIAGNOSIS 



tube. The abdominal portion of the tube has the greatest capacity and 
here the distention is accordingly greatest, while the uterine portion 
dilates but httle and the interstitial segment rarely takes part in the 
distention at all. The thickness of the tumor wall is variable and 
determines the distensibility of the tube. If there is little infiltration, 
the wall yields readily and the distention is proportionately great. 





Fig. -'79. — Hydrosalpinx with Ovary. 
(Specimen from the Kgl. XJniversitats- 
Fraufinklinik in Konigsberg.) 



Palpatory Findings. 

The palpatory findings in retention 
tumors, which form the basis of diag- 
nosis, vary according to the conditions 
present (see Fig. 278) — old processes 
with thin, watery contents (hydro- 
salpinx), more or less recent active 
processes with suppuration (pyo sal- 
pinx), or ah accumulation of blood 
in the tube (hematosalpinx). For 
conditions will be treated separately. 

tumor, which is usually 
the following properties : 




this reason these three 

Hydrosalpinx represents a thin-walled 
filled with simple serous fluid. It has 

The shape of the hydrosalpinx 
depends in the main on the distribution 
of the contained fluid; as most of the 
contents accumulate in the abdominal 
portion, the typical shape of the hydro- ji^ 
salpinx is that of a club with a very thick ff^,^ 
extremity. Preformed tortuosities in the I ^ 
tube, with an abundance of folds in the \ 
lumen, may alter the shape by dividing 
the tube into separate portions; or, if 
they lead to complete occlusion, convert 
the abdominal portion into approxi- 
mately round tumors contrasting sharply 
with the less distended uterine segment (Fig. 280). The shape is 
greatly influenced by the relations of the tube to the mesosalpinx, which 
is too short for the tube and, if the latter is distended with fluid, forces 
it to form tortuosities as in the case of the intestine and mesentery. 
The tortuosities usually occupy the median half, which is attached by 
a pedicle to the uterus and pelvic floor. In this way the characteristic 
convolutions of tubal tumors are produced (Fig. 278 j and 2782). 

In- exceptional cases hydrosalpinx develops between the layers of 
the broad Hgament. In such a case tortuosities are not produced (at least 
they cannot be felt as in the case of a freely movable tube), and the hydro- 



FiG. 280. — Htdrosalpin-x with Sac- 
cular Dilatation of the Abdominal 
Extremity. (Specimen from the l\ir\. Uni- 
versitats-Fravienklinik in Konigsberg.) 



SPECIAL DIAGNOSIS 



455 



salpinx represents an approximately round tumor with a fairly smooth 
surface, covered with peritoneum. If part of the contents is absorbed, 
the hydrosalpinx collapses and feels like a flat, ribbon-shaped structure. 
The position of the hydrosalpinx corresponds in the main to 
the position of the normal tube. The uterine portion is always in its 
place, while the dilated fimbriated extremity lies deep in Douglas' 
space or in contact with the lateral or posterior surface of the uterus; 
in rare cases above, and adherent to the fundus. Most frequently the 
abdominal extremity is found in front of the sacro-iliac articulation, in 
the lateral portion of Douglas' space. Occasionally the tube is bent 
over forward and occupies the vesico-uterine excavation. Great varia- 
tions in the position are possible if the mobility of the tube has not been 
abolished by adhesions. Intraligamentary tubal tumors are held near 




Fig. 281. — Intraligamentary Hydrosalpinx op the Right Side. P.-F. J^. (Original.) The 
tumor cannot be differentiated from the uterus and is fixed by exudates at its base ; above, the thickened 
uterine portion of the tube is distinctly felt. 

the uterus by the broad ligament, usually fill out that structure, 
and lie close to the body. If they are large enough they push the free 
edge of the ligament upward and project above the fundus, but they 
rarely grow downward into the deeper portions of the parametrium. 

The mobility depends on the degree of the accompanying pelvic 
peritonitis and its sequelae. Sometimes the hydrosalpinx is as movable 
on its mesosalpinx as an ovarian tumor on its pedicle. If the broad 
ligament is relaxed, the mobility may attain a high degree. I once saw 
a hydrosalpinx the size of the fist, which could easily be pushed up as 
high as the costal arch. Often intraligamentary tumors may be quite 
movable if they do not involve the median portion of the ligament. 
Such cases are, however, exceptional. As a rule peritonitis occurs 
early and leads to adhesions around the abdominal extremity, which 
becomes fixed wherever it happens to be, at the lateral or posterior 
surface of the uterus, on the floor of Douglas' space, or at the pelvic wall. 



456 



GYNECOLOGICAL DIAGNOSIS 



The mobility of the tumor depends on the length and rigidity of 
the adhesions with the pelvic wall and with the parietal peritoneum; 
adhesions from contracting parametritic exudates are rare. 

The consistency in hydrosalpinx is always distinctly cystic 
because the wall is thin and the fluid quite movable. It is only when 
the tumors are small, or surrounded by exudates, or adherent to the 
intestines that fluctuation is difficult to demonstrate. The rigidity of 
the tumor wall depends on the degree of distention. If part of the 
contents has been evacuated or absorbed, the tumor loses its cystic 
consistency and becomes flat and soft, and sometimes feels like a band. 

The tenderness which 
is present in tubal diseases is 
not due to the hydrosalpinx 
itself, but depends rather on 
the accompanying inflamma- 
tion; in recent conditions it is 
usually intense, while it may 
be entirely absent in old cases. 
Pyosalpinx results from the 
retention of large quantities of 
pus in suppurative salpingitis. 
As small quantities of pus 
cannot be demonstrated clini- 
cally, the term pyosalpinx is 
employed, as distinguished from 
purulent salpingitis, only when 
the abdominal extremity is dis- 
tinctly dilated. In the main the features and peculiarities of pyosal- 
pinx are the same as those of hydrosalpinx, modified, however, by the 
intensity of the inflammatory process and pai'tly by the 
thickness of the wall. In general the tumors are much 
smaller, partly because a smaller quantity of pus is produced and 
partly because the thickened wall resists distention. 

Shape. Marked tortuosity is much more rare in pyosalpinx 
because the thickened wall prevents it; if the distention is moderate, 
the tumor is usually club-shaped (Fig. 283), while in profuse suppura- 
tions it becomes spherical. The shape of an intrahgamentary pyosal- 
pinx is absolutely spherical. The tumor is surrounded by the inflamed 
and thickened layers of the broad ligament, and the characteristic 
tubal outline is entirely lost. 

The position in pyosalpinx is always more constant than in 
hydrosalpinx because of the many adhesions and early occurrence of 
fixation. If the uterus is in its normal position, the pyosalpinx usually 




Fig. 282. — The Same in Horizontal Cross Section. 
P.-F. 5-3. (Original.) On the right side the tumor is 
fixed to tlie pelvis by perimetritic adhesions. The poste- 
rior layer of the broad ligament has been pushed up, and 
the tumor is in contact with the posterior surface of the 
uterus. On the left side a section of flaccid tube is 
indistinctly palpable. 



Pyosalpinx. 



SPECIAL DIAGNOSIS 



457 



corresponds to the regular course of the tube, with the abdominal extrem- 
ity directed backward and downward. The latter is almost always at 
the posterior pelvic wall, sometimes high up, but usually low down in 
Douglas' space or at the lateral aspect of the uterus. 

Cystic consistency and fluctuation can be demonstrated only 
in large tumors. On account of the thickness of the wall and surround- 
ing exudates, moderate quantities of pus cannot be recognized. In most 
cases of pyosalpinx the consistency is hard and unyielding, except at 
the abdominal extremity, where the tumor is somewhat softer. 

The mobility in pyosalpinx also depends on the extent and 
firmness of the adhesions. Absolutely movable pyosalpinx without 
any adhesions is rare; as a rule the abdominal extremity is early sur- 




FiG. 283. — Right-Sided Pyosalpinx. P.-F. J^. (Original.) Club-shaped pyosalpinx, separated by 
exudates from the lateral surface of the uterus. 



rounded and firmly fixed to the posterior pelvic wall by dense adhesions, 
while the anterior segment together with the uterus may retain its normal 
mobility. If extensive pelvic peritonitis is superadded, the entire tube 
becomes enveloped in adhesions to the uterus, parietal peritoneum, 
bladder, rectum and ovaries, gradually limiting the mobility or abolishing 
it altogether if the pelvic adhesions are sufficiently broad. As a result of 
parametritic exudates the tumor may be firmly cemented to the pelvis 
(Fig. 284) ; this is particularly the case with intraligamentary pyosalpinx. 

The tenderness in pyosalpinx depends chiefly, but not exclu- 
sively on the accompanying pelvic peritonitis; in recent cases it is very 
intense, while in old, chronic cases it may be entirely absent. 

Hematosalpinx, or the accumulation of hemorrhagic fluid in an 
occluded tube, occurs in connection with hematometra in atresia of 
the genital organs, or from hemorrhage into a hydrosalpinx the result 
of torsion or traumatism. Accumulation of pure blood in the gravid 



458 GYNECOLOGICAL DIAGNOSIS 

tube is not included in the present discussion (see p. 146). Hematosal- 
pinx has nothing characteristic and closely resembles hydrosalpinx, 
because the inflammatory process is mild, whether it be causal or 
merely secondary. If the distension is great, or if pure' blood is 
coagulated in the tube, the consistency is usually very much harder. 

Diagnosis. 

The diagnosis of a tubal tumor is based on the finding of a tumor 
alongside of the uterus and separated from it; the tubal origin of the 
tumor is recognized by the above-described properties. 

The shape of a hydrosalpinx may be sufficiently characteristic 
to establish the diagnosis by itself. The sausage-shape should be noted 




Fig. 284. — Left-Sided Pyosalpinx, •with a parametritic exudate under the abdominal extremity. P.-F. 
Vi. (Original.) The right tube is somewhat thickened. 

and tortuosities looked for in the uterine portion. Sometimes the 
individual portions of the tube are represented by so many nodes lying 
side by side. The tortuosities that are directed toward the abdominal 
walls are particularly easy to recognize as the outer fingers pass over 
Diagnostic them, while those directed downward are more apt to be 

Features. inaccessible to palpation. Sometimes the tortuosities of the 

uterine extremity lie on top of the dilated abdominal extremity (Fig. 
278J as in the case of an ovarian cyst. If the convolutions of the tube 
are close together they cannot be made out by palpation, and all that 
can be felt is a few constrictions on the surface of the roundish tumor. 
"When the tumor is intraligamentary, its characteristic shape is obscured 
by the peritoneal investment. If the hydrosalpinx is adherent to the 
uterus it also represents mereh' a roundish tumor, sometimes difficult 
to differentiate and without any characteristic shape, which is com- 
pletely obscured by the adjacent ovary, the surrounding exudates, and 



SPECIAL DIAGNOSIS 



459 



adhesions with the intestines. Pyosalpinx is recognizable by its shape 
only if the tumor is more or less cylindrical, with a club-shaped extremity; 
tortuosities are more rarely felt. The shape is often completely 
obscured by perimetritic adhesions and parametritic exudates around the 
abdominal extremity. If the tumor is between the layers of the broad 
ligament or adherent to the uterus, it resembles an approximately round 
or oval tumor and is in no wise characteristic. 

The position of the tumor may reveal its tubal origin if it corre- 
sponds to the course of the tube, especially if the main tumor occupies 
the site of the infundibulum in the lateral portion of Douglas' space. 

Mobility and consistency are not pathognomonic of tubal tumors. • 




Tubal Cord. 



Fig. 285. — Right-Sided Hydrosalpinx. P.-F. h- (Original.) On the right, the thickened 
tubal cord is distinctly palpable, the outer e.^tremity merging with the tumor. On the left, a section of 
sausage-shaped, flaccid tumor is palpable. 

In addition to the above properties, which may occasionally sufhce to 
establish the diagnosis, there are certain other signs of very great value. 

A thick cord running from the cornu of the uterus to the tumor 
is an invaluable sign of tubal tumor. The cord is the infiltrated and 
non-dilated uterine portion of the tube, which is so constant in inflam- 
matory tubal tumors because the inflammation begins in 
the uterus and first attacks this portion of the tube. The 
greater the infiltration the more distinctly will the cord be felt. In old 
cases of hydrosalpinx the tubal wall may become so thin from absorp- 
tion that it can no longer be felt. The cord is felt most distinctly when 
the uterus is raised from within, and the examining hand is passed up 
and clown in the anteroposterior direction alongside of the cornu of 
the uterus. The lateral portion is usually more indistinct and merges 
with the tumor, or may be traced for a certain distance on the tumor 
wall (Fig. 285). The cord is cjuite distinct even when the tumor is intra- 
ligamentary (Fig. 281). It is particularly important to demonstrate this 



460 GYNECOLOGICAL DIAGNOSIS 

tubal cord when the entire tube, along with the ovary, intestines, bladder 
and peritoneal cysts, forms an indefinite tumor. I regard thickening of 
the uterine portion of the tube as the most reliable sign of a tubal tumor. 
The fact that the disease is bilateral is a very important diag- 
nostic feature because in almost every case both tubes are attacked at 
the same time or in rapid succession. An absolutely uninvolved tube 
Bilateral ou One side when the other tube is the seat of distinct alter- 

Distnbution. atiou is a pathologic curiosity, and clinically also it is far 
more frequent that both sides are distinctly involved. One must not 
of course expect to find the same kind of tumors on both sides; this 
occurs only in a limited number of cases. Frequently the intensity and 
extent of the process vary on the two sides and the alterations are ac- 
cordingly different. Pyosalpinx of one side may be associated with 
hydrosalpinx of the other. Well marked retention tumors with puru- 
lent or catarrhal contents on one side may be associated with salpingitis 
on the other. In fact, the mere finding of an indistinct thickening of the 
adnexa, or fixation localized chiefly at the cornu of the uterus, or pain 
limited to the region of the adnexa, on one side, when there is a tumor 
on the other, is enough to characterize the condition as bilateral and is 
an argument in favor of the tubal origin of the tumor. If there are 
several large tumors side by side in Douglas' space, it may be difficult 
to determine whether they form one or two masses; in the latter case 
a distinct furrow is usually made out, or, if the greater portion of the 
tumor is near the pelvic wall, it becomes smaller toward the median 
line. It is to be observed that this sign is only of limited value, as ovarian 
tumors of other kinds are not infrequently bilateral. Myomata even 
may be present on both sides of the uterus, exudates may be bilateral; 
but tubal disease is by far the most common bilateral condition that 
occurs in the adnexa. 

Perimetritic and parametritic inflammations play 
an important role in the diagnosis of tubal diseases because the infection 
almost regularly spreads from the tube to the pelvic peritoneum and 
occasionally also to the parametrium. Acute peritonitis 
^erime n ic sliould arouse the suspicion of a tubal disease, especially if 
FnAaSmltioiis. ^^ represents a recurrence. Although the accurate demon- 
stration of a diseased tube may be impossible during the 
acute stage of pelvic peritonitis, pain localized near the adnexa is 
always strongly suggestive of tubal disease. After the acute stage has 
run its course, there remain indistinctly palpable, extremely sensitive 
tumors in the region of the adnexa, which consist of the tubes, the 
swollen ovaries, adherent coils of intestine, and small peritoneal cysts. 
The shape of the tube is more distinct in proportion to the duration of 
the process, and around the tube there remain numerous adhesions 



SPECIAL DIAGNOSIS 461 

with the adjacent organs and the pelvic wall, especially at the abdominal 
extremity. Parametritic inflammation occurs chiefly with purulent 
salpingitis and, in the acute stage, leads to the production of painful 
exudates underneath the tube, especially the fimbriae, and ultimately 
to parametral cicatrization in the form of a diffuse, cord-like thicken- 
ing. In these various stages pelvic peritonitis, and more rarely para- 
metritis, is an almost regular concomitant of tubal disease, and, if it is 
localized in the region of the adnexa, is a strong argument in favor of 
the tubal origin of an otherwise doubtful tumor; for, although inflam- 
matory complications occur with ovarian tumors, hematomata and myo- 
mata, they are by no means so frequent nor so extensive as in the case 
of tubal tumors. The complicating pelvic peritonitis sometimes takes 
the form of so-called adnexal tumors, which present considerable diag- 
nostic difficulties. These adnexal tumors in the narrower sense of the 
term, in contradistinction to the typical retention tumors, are small 




Fig. 286. — Fundus of Uterus with Bilateral Purulent Salpingitis. 

formations near the upper portion of the uterine body, consisting of 
the thickened and coiled up tube, the inflamed and enlarged ovary, 
adherent omentum and intestinal coils, and small masses of exudate 
among the peritoneal adhesions. These structures are so matted 
together that it is impossible to differentiate the individual constituents 
of the mass by palpation, and its tubal origin can only be inferred. 
When the altered adnexa are inaccessible to palpation they cannot be 
differentiated even by the most careful examination. Whereas in the 
normally situated uterus the adnexal tumor may be recognized as tubal 
by the thickened uterine extremity of the tube, which is distinctly 
palpable, all that one obtains by physical examination when the uterus 
is in retroposition or retroflexion is a general impression of a tumor of 
the upper portion of the adnexa. The bilateral character, the tender- 
ness, the many adhesions with surrounding structures, the semi-soft 
consistency are sufficient to characterize the tumor as tubal. 

The presence of gonorrheal catarrh may indicate the diag- 
nosis of tubal tumor because gonorrhea is the most frec^uent cause; 
if gonorrhea cannot be definitely demonstrated in the woman, the 
presence of the disease in the husband is equally suggestive. 



462 GYNECOLOGICAL DIAGNOSIS 

The diagnosis may also find some support in the history of the 

case, which may suggest the inflammatory character of the tumor. If it 

is learned that the tumor is the result of an old pelvic peritonitis, it is 

reasonable to suspect a tubal tumor; or, if the woman 

Anamnesis. _ . i ;> i • ... 

states that the attacks or pelvic peritonitis recur from 
time to time and that she feels well or at least better during the inter- 
vals — in other words that the pelvic peritonitis is of a relapsing type — 
the tumor is very probably a gonorrheal pyosalpinx. The statement 
that the disease began soon after marriage heightens the suspicion of 
infectious tubal disease. 

The symptoms are never sufficiently characteristic to establish 
the diagnosis, although recurrent attacks of pain distinctly localized 
in the side are very probably due to tubal disease. 

Exploratory puncture is a diagnostic procedure which can 
and ought to be replaced by accurate palpation. Even with antiseptic 
precautions it is not without danger, as it may cause infection and 
Exploratory suppuratlou of an aseptic tumor or evacuation of part of 
Puncture. ^j^g coutcuts of a pyosalpiux into the abdominal cavity. 

As in addition the fact that blood, serous fluid, or even pus is obtained 
gives no positive information as to whether the material was inside or 
alongside of the tube, the results of exploratory puncture add nothing 
to the accuracy of the diagnosis. The procedure should therefore be 
abandoned except for the purpose of examining the pus in order to 
determine the variety of microorganisms present (see p. 67). 

Differential Diagnosis. 

A number of conditions must be considered in the differential 
diagnosis of retention tumors, depending on whether we have to deal 
with a distinctly cystic hydrosalpinx or a hard, thick-walled pyosalpinx. 

Hydrosalpinx is most frequently confounded with cystic ova- 
rian tumors. The physical signs in the two conditions may be quite 
similar. Even after the abdomen has been opened, it may be impossible 
Ovarian to make out the origin of the tumor by inspection; but the 

Tumors. differential diagnosis is especially difficult when the tumor 

is intraligamentary, and neither its shape nor its connection with 
the uterus can be distinctly made out. An attempt must always be 
made to find the thickened uterine portion of the tube. The fact that 
the tumor is bilateral and the presence of inflammatory processes in 
the neighborhood are also in favor of tubal tumor. The diagnosis is 
easier when the hydrosalpinx is free and pedunculated; whereas an ova- 
rian tumor is always round or oval and freely movable, or at most held 
fast by a few adhesions at the base, hydrosalpinx in most cases, 
although not always, presents the familiar cylindrical, tortuous or club- 



SPECIAL DIAGNOSIS 463 

shaped outline and is usually attached to all the neighboring structures 
by numerous perimetritic adhesions. The examiner should always try 
to palpate the tube. In the case of an ovarian tumor it is often found 
normal in length and thickness, lying in front of the tumor; while in 
hydrosalpinx the uterine portion is thickened and the lateral extremity 
merges gradually with the tumor wall. On account of the many adhe- 
sions it is usually impossible to feel the ovary alongside of the hydrosal- 
pinx. The above-mentioned historical data and the demonstration of 
gonorrhea occasionally help to establish the tubal character of the tumor. 

The diagnosis between hydrosalpinx and parovarian cyst maybe 
still more difficult because of the impossibility of outlining the tube and 
the fact that the ovary is sometimes distinctly felt alongside of the tumor. 

For a differential diagnosis between hydrosalpinx and encap- 
sulated peritoneal exudates, see the latter. 

Pyosalpinx. Failure to recognize this as a tubal tumor is much 
more common on account of the thick wall of the pyosalpinx. Pyo- 
salpinx is easily mistaken for a solid tumor. For instance, a pyosalpinx 
with a greatly infiltrated wall and a small quantity of pus in its interior 
may be mistaken for a pedunculated subserous myoma, subserous 

especially if the tube is coiled up and hidden under masses Myoma. 

of exudate, or the tumor is intraligamentary. The myoma can be recog- 
nized only on careful palpation by its round shape, free mobility and 
the absence of pain; while the outline of a tubal tumor is more vague 
on account of the surrounding exudates; palpation is painful; and the 
tumor is usually firmly adherent to the neighboring structures. The 
presence of two symmetrical tumors, one on each side, is also in favor 
of a tubal origin. The peduncular attachment to the uterus is different 
in the two conditions. In pyosalpinx the pedicle is thin and merely con- 
nects the cornu of the uterus with the tumor, while the remaining portion 
of the tumor is in relation with the outer surface of the uterus and can be 
separated from it. In subserous myoma, on the other hand, the pedun- 
cular connection is much broader, as a large portion of the periphery 
of the tumor is in the uterine wall. Leukocytosis is a valuable auxil- 
iary in the diagnosis of the individual forms of pyosalpinx. The 
data obtained from the history may also assist in the differential diag- 
nosis, as has been explained. In these cases also exploratory puncture, 
although an easy method of distinguishing between a solid and a 
pus-containing tumor, should be avoided on account of its dangers. 

For the differential diagnosis between pyosalpinx and parametritic 
exudates, see the latter. 

Tubal pregnancy for obvious rea.sons may produce conditions 
closely resembling those of inflammatory tubal disease, especially 
tubal mole or retention of a dead ovum with hemorrhages in the lumen, 



464 GYNECOLOGICAL DIAGNOSIS 

the physical signs of which are often indistinguishable from those of 
purulent salpingitis or pj^osalpinx. If it is remembered that tubal 
pregnancy frequently develops on the foundation of an inflammatory 
Tubal tubal disease and, on the other hand, that inflammatory 

Pregnancy. couditions may result from imperfect absorption of the 

tubal pregnancy, it is no wonder that the diagnosis is absolutely impos- 
sible in many cases of long standing. In recent cases, on the other 
hand, the differential diagnosis ma)'' be said to be possible for the fol- 
lowing reasons: If the tube is greatly distended with clotted blood, 
the tubal mole is usually much harder than a pyosalpinx; while, 
owing to the absence of extensive inflammation, there is a total freedom 
from adhesions and the tumor is practically painless. A characteristic 
feature of tubal pregnancy is that the uterine extremity of the tube is 
not involved unless, in exceptional cases, implantation has taken place 
near the uterus ; whereas in the presence of inflammatory tubal disease 
the tube is characteristically thick and hard. If it can be absolutely 
demonstrated that the other side is not involved, tubal pregnancy is 
much more probable than inflammation. Pedunculated tubal hema- 
tocele, and occasionally a laterallj^ situated retro-uterine hematocele, 
may be mistaken for hydrosalpinx on account of the cj^stic con- 
sistency, at least in the early stages. A thin wall, uniform consistency 
and distinct fluctuation are all in favor of hydrosalpinx; whereas in 
hematoma no distinct wall can be palpated, the tumor merging with the 
neighboring structures; the consistency is variable; and, above all, there 
is a gradual hardening as coagulation takes place. Under these cir- 
cumstances also the character of the uterine extremity of the tube may 
establish the diagnosis. Whenever tubal pregnancy has to be distin- 
guished from tubal inflammation, the historical data described in these 
two afl'ections play an important part. 

The differential diagnosis between the right-sided tubal disease 
and perityphlitis or appendicitis is of the greatest practical 
importance. Errors in both directions are very frequent. Owing to 
the constantly increasing importance of appendicitis in 
en j-p 1 IS. i-ecent years, the diagnosis of this condition is unques- 
tionabty made too often. The source of error resides in the spatial 
proximity of the two organs, and particularly in the fact that the two 
processes are interdependent and often associated. An adherent appen- 
dix ma}^ infect a tube, or the latter ma}^ become involved in a con- 
tiguous perityplilitic exudate. Conversely, appendicitis may develop 
secondarily when the appendix becomes adherent to the diseased tube, 
and a perisalpingitic process may extend to the cecum. The symptoms 
of the two conditions also may be very similar, since recurring attacks 
of peritonitis with acute onset and continuous pain in the affected side 



SPECIAL DIAGNOSIS 465 

are characteristic of both. Hence, unless distinct intestinal symptoms 
such as colic, symptoms of stenosis or, on the other hand, gynecologic 
symptoms such as hemorrhage, vaginal discharge or dysmenorrhea are 
decisive one way or the other, but little may be expected from the 
symptomatology in the differential diagnosis between the two condi- 
tions. It should, if possible, be made by means of an objective exami- 
nation. By external examination the seat of the exudate should first 
be determined. If it is found on the iliac bone, or possibly the infiltrated 
and tender appendix can be direct!}' felt in that region, the diagnosis 
of typhlitis or appendicitis is practically certain, provided the genitalia 
are later found to be uninvolved. Pain on pressure alone must be inter- 
preted with great caution because forcible depression of the abdominal 
w^all at this point is equally painful in uncomplicated genital affections. 
Bimanual examination will often at once clear up the diagnosis in simple 
cases if the tumor is felt entering the pelvis from above, while the origin 
of the tubes is free; or, conversely, if the tumor is distinctly localized 
in the tube and the other adnexa are possibly also diseased. Difficulties 
are encountered in those cases in which the intestinal exudate approaches 
the genitalia, or vice versa. In such cases the starting point of the mor- 
bid piocess may sometimes be recognized by the course or by the site 
of the centre of the exudate. Combinations of the two processes, even 
when they are riot interdependent, present difficulties when an intestinal 
inflammation is superadded to an old genital disease, or vice versa. 
One is always inclined to attribute the new symptom to the old process, 
and repeated accurate local examination is the only means of guarding 
against a mistake in diagnosis. 

Diagnosis of Certain Special Conditions. 

After the diagnosis of inflammatory tubal disease has been estab- 
lished, the etiology remains to be determined. Aside from the scientific 
interest, this question is important to the practitioner because the prog- 
nosis and treatment are materially influenced by the variety of microor- 
ganisms which has produced infection and by the specific tissue reaction. 

Of the microorganisms that are capable of producing tubal disease the following have 
been found in the tube: gonococci, tubercle bacilli, streptococci, staphylococci, pneumo- 
cocci and actinomyces. The frequency of the most important varieties is determined by 
examination of the pus obtained from tubal sacs, as sho^mi in the following table. 

Sterile. 

Wertheim II. (114 cases) . .57 

Menge (112 cases) 75 

Witte (39 cases) 24 

Although these results, with regard to tubercle bacilli especially, show marked differ- 
ences, it is nevertheless evident that gonorrhea is by far the most frequent cause, when it is 
remembered that gonococci are rapidly destroyed and that the great majority of cases in 
-which pus is reported as sterile are also gonorrheal. 

30 



Gonococci. 


Tubercle Bacilli. 


Streptococci. 


Staphylococci. 


39 




11 


5 


28 


9 


4 


1 


7 




4 


2 



466 GYNECOLOGICAL DIAGNOSIS 

Gonorrhea, tuberculosis and septic salpingitis are 
the only conditions that have any practical importance. In most cases 
the differential diagnosis between these three varieties is possible and 
is based, first on the objective examination and, second, on the 
symptoms and the course of the disease. If these means fail, a bacte- 
riologic examination of pus obtained by aspiration may be made in 
particularly important cases. 

Since gonorrheal salpingitis is by far the most frequent 
form of tubal inflammation, being present in from 80 to 85 per cent, 
of all cases, it may be assumed unless there are definite reasons for 
suspecting some other form of infection. On examination the tubes 
show nothing characteristic to distinguish this from the septic form, 
while tuberculosis can often be differentiated from either. If exten- 
sive parametritic exudates are found underneath the tube, the 
condition is probably not gonorrheal. Small exudates may be present 
with gonorrheal pus-tubes. If gonorrhea is positively demonstrated 
in the lower portions of the genitalia, particularly the uterus, tubal 
disease may be attributed to the same cause with a fair degree of prob- 
ability; but if no signs of gonorrhea are found in the uterus, gonorrheal 
pyosalpinx must not be excluded on that account, as the disease tends 
to subside in the mucous membrane and infection in the uterus may 
be present without producing any symptoms. Useful information is 
usually obtained from the history. If the salpingitis develops after 
menstruation, and especially a short time after the beginning of marital 
intercourse, the condition is very probably gonorrheal. Gonorrhea in 
the husband is also an important diagnostic point. 

The septic form, which is due to infection with staphylococci 
and streptococci and may be estimated as representing from 5 to 10 
per cent, of all cases, is difficult to diagnose on account of the paucity 
of the physical signs, among which I may mention the presence of 
extensive parametritic exudates associated with protracted fever that 
can only be referred to the tubes. As a rule fever of a few days' dura- 
tion occurs only at the beginning of a gonorrheal infection or recurs 
with subsequent exacerbations, while in septic salpingitis, possibly 
owing to the constant production and absorption of fresh toxines, 
the fever may continue for months and may return again and again at 
the time of menstruation. But little information is obtained from the 
history. The fact that the tubal disease followed infection during the 
puerperium is not diagnostic, because gonorrhea very frequently appears 
in the tube during the puerperium. The same thing applies to salpin- 
gitis developing after curettage and sounding of the uterus or uterine 
treatment of tubal infection, because these manipulations also permit 
extension of the gonorrheal process to the tubes. 



SPECIAL DIAGNOSIS 467 

Tuberculous salpingitis is so well characterized by its symp- 
toms, course and physical signs that the diagnosis is usually possible. 
The incidence may be estimated to be about 5 per cent. The condition 
of the tubes themselves is not particularly characteristic. As tuber- 
culosis is accompanied by marked infiltration of the walls and suppura- 
tion, if it occurs at all in typical form, develops late, the tubes are found 
very much infiltrated, and somewhat rough or nodular if infantile tor- 
tuosities are also present. If the infection is derived from the uterus, 
the nodes are most distinct in the uterine extremity. If pyosalpinx 
develops, these signs are not present. As tuberculosis is either derived 
from the peritoneum or extends to that membrane, signs of peritoneal 
disease in the form of ascites or peritoneal nodules (see p. 472) are 
almost regularly present. The combination of ascites and swelling of 
the tubes is an almost positive sign of tuberculosis; for, although ascites 
also results quite frequently from neoplasms of the tube, that condition 
is extremely rare. Signs of tuberculosis in the genitalia, such as tuber- 
culous ulcers or tuberculous endometritis, confirm the diagnosis. The 
presence of tuberculosis in other organs renders the diagnosis very 
probable; hence the lungs, the bones, the joints, the intestines and the 
skin must also be investigated. In one case the diagnosis was sug- 
gested to me by lupus of the face. The symptoms and the patient's 
general condition are of very little value. Doubtful cases may be 
cleared up by resorting to the tuberculin reaction. Heredity and 
the history of previous scrofula and tuberculosis are the only factors 
of value in the history. Exploratory puncture for the purpose of 
clinching the diagnosis by an examination of the pus is dangerous and 
should be employed only when in a serious case an important thera- 
peutic intervention, such as incision of a septic pyosalpinx, depends 
on the result of the examination. As in more than half of all the 
cases, particularly when the process is old, the pus is sterile, the results 
of exploratory puncture are of very little real value. 

Prognosis and the treatment to be employed in an individual 
case may depend on the contents of" the tubal tumor; in other words, 
it is often important to differentiate between the three kinds of reten- 
tion tumors. Hydrosalpinx can sometimes be dis- 

. Contents of 

tinguished from pyosalpinx by palpation, although it Retention 

must be remembered that the change from one to the other 
is gradual. Thin walls, fluctuation, mobility, marked tortuosities are 
in favor of hydrosalpinx; while pyosalpinx is usually small, harder, 
attached by a broad base, associated with exudates, and often more 
sensitive on pressure. Hematosalpinx can be diagnosed with some 
degree of certainty only when the most common cause, occlusion of 
some of the lower genital segments, is demonstrable; the history of a pre- 



468 GYNECOLOGICAL DIAGNOSIS 

vious tubal pregnane}' is also suggestive, but not positive evidence of 
hematosalpinx. Leukocytosis affords a valuable means of recognizing 
the most important contents of the tubal tumor, namely pus. 

It has been shown by Dutzmann, Pankow and others, who laave made systematic 
leukocyte counts and confirmed the diagnostic significance of the sign by the results of opera- 
tions, that a distinct leukocytosis is almost always present in suppurative salpingitis. On the 
other hand, the actual number of leukocytes is smaller than in the case of recent abscesses 
and, as a rule, does not exceed, nor fall much below 15,000. The reason probably is that 
after the acute process has rim its course, leukocytosis slowly subsides on account of the death 
of the microorganisms, although the pus stiU. persists. Hence a comparatively low leukocy- 
tosis demands consideration in the diagnosis. According to Pankow's results a persistent 
leukocytosis of 15,000, provided of coui'se every other cause has been excluded, indicates pus; 
but a count of less than 10,000 does not exclude its presence. The low figures may be in part 
also attributable to gonorrhea, which, on account of its local character, produces a consider- 
ably lower leukocytosis. In 10 cases of tuberculous pyosalpinx examined by Dutzmann and 
Pankow leukocytosis was constantly absent, while in streptococcal infections large numbers 
of leukocytes were always found. 

On the strength of these observations leukocytosis may be utilized 
with certain reservations for the diagnosis of pus in tubal disease; 
indeed it almost seems to afford a means of differentiating the various 
forms of pyosalpinx. 

Exploratory puncture is of course a very reliable means of deter- 
mining the contents of a tumor, but it should be employed only after 
all other means have failed and when the question of operaton depends 
on the result. 

Diagnosis of Perforation. 

Perforation of a pyosalpinx is a bad complication because it pro- 
duces a cavity which constantly secretes fetid pus, and not only occa- 
sions great annoyance to the patient but seriously undermines her health- 
The diagnosis of existing and impending perforation is therefore not 
without importance. Perforation may take place into the rectum, 
bladder, vagina, or to the outer air through the abdominal walls. As 
perforation is always preceded by the formation of large exudates, 
through which a communication with the respective hollow organ by 
means of a fistula is established, the tubal tumor loses its characteristic 
shape and becomes surrounded by large, usually parametritic, masses 
of exudate, which bind the tumor to the hollow organ into which rup- 
ture has taken place. The first sign of perforation is the discharge of 
pus with the feces or urine, into the vagina or through an opening in the 
abdominal wall; the flow is usually abundant and the pus has a pene- 
trating odor. The fistula in the abdominal walls or in the vagina, where 
it is readily detected between the folds of mucous membrane by the 
infiltration at the base and purulent discharge from the fistular orifice, 
must be sounded, and the direction of the sound with respect to 



SPECIAL DIAGNOSIS 469 

the tube noted. The opening of the perforation into the rectum is 
sometimes so small that it cannot be felt, but it is always found at the 
point where the exudate is closest to the rectal wall. Perforation into 
the bladder is recognized with the cystoscope. 

In a case of tliis kind Kolischer found a cleft-shaped opening surrounded by fringed 
edges, from which there projected a small, yellowish, sausage-shaped mass, grooved in the 
longitudinal direction, which became elongated as the adnexal tumor was compressed, causing 
the pus to separate and deposit itself on the floor of the bladder. 

The diagnosis of perforation in pyosalpinx is accordingly based on 
the presence of a tubal tumor and the discharge of pus from an organ 
to which the tumor is attached by a broad base. The differential diag- 
nosis from perforation of an exudate is based on the fact that the tumor 
has a round contour and on the fetid odor of pus, indicating that it 
has been retained for some time in a large sac. 

The diagnosis of impending perforation is suggested by the pres- 
ence of an exudate which is approaching the corresponding organ, and 
by marked febrile movements. This preparatory stage gives rise to 
characteristic changes in the abdominal walls, the vagina, the rectum 
and bladder, which will be described in connection with abscess forma- 
tion in parametritic exudates (p. 495). 

Neoplasms of the Fallopian Tubes. 

Neoplasms of the tubes are very rare. The benign formations that 
have been observed are papilloma and fibroma. Among malignant 
neoplasms may be mentioned carcinoma, sarcoma, and xubai 

chorio-epithelioma. The only ones that arc frequent Neoplasms, 

enough to have any practical significance are papilloma and carcinoma. 

Papillomata are as a rule unilateral neoplasms of the tubal 
mucous membrane, developing on an inflammatory base. The newly 
formed masses fill the interior of the tube and may produce tumors of 
considerable size. The papillomatous folds, like uterine papillomata, 
secrete a serous fiuid which either collects as freely movable ascites in 
the abdominal cavity or, if the abdominal extremity of the tube is 
closed, escapes from the uterus. As these tumors originate in chronic 
infiammations, a tentative diagnosis may be based on the observation 
of increased growth in chronic adnexal tumors, with the production of 
ascites and an intermittent flow of serous fluid from the uterus 
(hydrops tubte profluens). 

The physical signs in carcinoma are the same as in papilloma, and 
the malignant nature of the tumor may be suggested by the greater age 
of the patient and the presence of cachexia. 

The diagnosis of these two neoplasms is exceedingly difficult. 



470 GYNECOLOGICAL DIAGNOSIS 



Diagnosis of Pelvic Peritonitis. 

( Pelveoperitonitis.) 

Pelvic peritonitis is inflammation of those portions of the 

peritoneum tlie parietal layer of which forms the covering of the upper 

portions of the true pelvis, the iliac bones, and adjacent portions of the 

anterior and posterior abdominal walls; while the visceral 

Definition. . -iiii 

layer invests the uterus, tubes, base or the ovaries, bladder 
and anterior portion of the rectum and forms the broad ligaments on 
each side of the uterus (see p. 82). In addition to pelvic peritonitis 
we commonly use the term perimetritis to designate inflammation 
of the serous covering of the uterus (although the term is generally used 
to include inflammation of the entire pelvic peritoneum in contradistinc- 
tion to parametritis), perisalpingitis for inflammation of the serous 
covering of the tubes and their immediate neighborhood, and perio- 
ophoritis for inflammation of the structures surrounding the ovary. 
Pelvic peritonitis may be a concomitant of general peritonitis 
originating in some of the abdominal organs, as after perforation of the 
stomach, intestines or gall bladder; such cases are not included in the 
present discussion. The gynecologist is chiefly interested in those forms 
of peritonitis which follow diseases of the pelvic organs, and which may 
either gradually spread to the entire peritoneum with the production of 
diffuse or general peritonitis, or confine themselves to the 
region of the true pelvis and its immediate neighborhood. A distinc- 
tion ought therefore to be made between general and circumscribed 
peritonitis; but as in the case of the former the inflammation may sub- 
side in the peritoneum generally and the pelvic inflammation which 
remains as a residuum may be identical with the pelvic peritonitis orig- 
inating in the pelvis, the distinction is very difficult and can usually 
be made only at the height of the morbid process. 

Diffuse Peritonitis. 

Diffuse peritonitis beginning in the genital organs usually originates 
in the true pelvis and extends to the entire abdominal cavity. When it 
is caused by large tumors of the ovaries and uterus it rarely develops 
primarily in the upper portion of the abdominal cavity. The cause is 
either infection of the abdominal cavity with microorganisms or some 
as yet ill undei'stood chemical or mechanical influence. A knowledge 
of these two etiologically distinct forms is very necessary, as they 
produce clinically different pictures. 



SPECIAL DIAGNOSIS 471 

I. Non=infectious peritonitis results from rupture and torsion of 
ovarian tumors; it accompanies papillary cysts and nutritional disturb- 
ances in cases of myoma and ovarian tumor; the condition is seen most 
characteristically in torsion of the pedicle. In this form the symptoms are 
limited to the abdomen and the general phenomena peculiar to the septic 
form are absent. There are meteorism, moderate tenderness, occasional 
vomiting, and a sluggish action of the bowels; while the pulse, tempera- 
ture and general condition show no change. Not infrequently the local 
phenomena are absent, and at the operation very marked changes, 
which may be much more pronounced than in septic peritonitis, are 
unexpectedly found. Hence the diagnosis cannot always be made; 
it is easiest when the above-mentioned symptoms develop in a case of 
tumor. The distinction from ileus is not always possible. Non-infec- 
tious peritonitis is much more frequently local and leads to the formation 
of adhesions in the case of tumors, encapsulation of blood and extra- 
uterine gestation sacs, uterine and ovarian adhesions, particularly in the 
presence of displacements (see p. 254). 

II. Infectious peritonitis. Depending on the microorgan- 
isms present we distinguish: 

1. Septic Peritonitis. This is caused by infection of the abdominal 
cavity with streptococcus and staphylococcus pyogenes, less frequently 
pneumococcus and bacterium coli, after an abdominal section; by 
rupture of a pyosalpinx, suppurative dermal cyst, gestation sacs, and 
hematoceles; and by perforation of a necrotic carcinoma. 

A further subdivision of infectious peritonitis in accordance with the causal septic 
microorganism into streptococcus peritonitis, bacterium coh peritonitis, etc., for chnical 
purposes is as yet impossible. 

The clinical picture on which the diagnosis is based is made up of 
local signs of irritation and the symptoms of general sepsis. 
The former consist in meteorism, singultus and the formation of an 
exudate; the latter in irregular heart action and loss of strength. The 
diagnosis presents no difficulties when all the symptoms, or at least the 
most important ones are present; but this is rarely the case, and any 
one of the cardinal symptoms may be wanting. The most constant, 
as well as the most important is meteorism, which may occur in 
any degree of severity from a barely perceptible increase in tension 
to extreme, drum-like distention of the abdomen. Meteorism subsides 
with every temporary diminution of the inflammation and increases 
again with every exacerbation; it is therefore the most valuable diag- 
nostic and prognostic sign of peritonitis. Tenderness on pressure 
is much less important, as it may be entirely absent in slowly pro- 
gressive cases with abundant exudate, and in cases of very severe 
septic inflammation. Vomiting is almost always present in diffuse 



472 GYNECOLOGICAL DL4GNOSIS 

septic peritonitis; black, liciuicl masses usually in small quantities 
are ejected without effort at short intervals. The most inconstant 
of all the symptoms is the presence of a clinically demonstrable 
exudate. In protracted cases, however, small movable masses of 
exudate can be recognized in the lumbar regions. Occasionally a large, 
freely movable collection, as in ascites, may be found. 

Among the general symptoms the most valuable is the increase 
in the frecjuency of the pulse- rate. It is never absent and 
is usually the first sign of beginning inflammation. In the severe septic 
forms tlxe pulse increases verj- rapidly and becomes small and irregular; 
in the milder forms the acceleration is much less. Fever is a much 
more inconstant symptom. It may be entirely absent or very slight 
in the gravest cases that rapidly terminate in death. In other cases the 
fever is moderate and rarely attains an excessive height. The course is 
not characteristic. The general appearance of the patient, 
especiall}^ the facial expression, may be so characteristic as in itself 
by mere inspection to suffice for diagnosis as well as prognosis. Rest- 
lessness, an anxious expression, wide open eyes and distorted features 
make up a picture which is absolutely typical of peritonitis. 

2. Tuberculous peritonitis usually attacks the entire peritoneum 
and leads to the secretion of a serous exudate and the eruption 
of tubercles in the entire abdominal cavity (peritonitis tuberc. 
Tuberculous adha^siva). Tuberculous ascites in most cases is fluid and 
Peritonitis. frecly movable; in other cases the fluid becomes encapsu- 

lated between the intestinal coils and the abdominal wall, producing 
flat cystic tumors of irregular outline and surrounded by adherent 
coils of intestines. In rare cases the two layers of the peritoneum be- 
come adherent without the production of a fluid exudate, and the 
mesentery and omentum contract and become shortened. Quite fre- 
quently a transverse area of resistance is found above the umbilicus, 
which corresponds to the adherent and matted omentum. The course 
is subacute or chronic, with moderate fever or without any fever and 
general symptoms, or with extreme emaciation. A positive diagnosis 
is not always possible. In all cases of freely movable exudate the 
diagnosis lies between tuberculous peritonitis and ascites. Under anes- 
thesia it is often possible by combined examination through the rectum 
and abdominal walls to feel the individual tubercles or to elicit a friction 
sound, so-called 'snow-ball crunching,' by rubbing the two layers of 
the peritoneum together. The presence of thickened and nodular tubes, 
as well as the discovery of tuberculosis in the intestines, lungs or skin, 
increases the probability of tuberculous peritonitis. Inoculation with 
tuberculin is an almost certain method of recognizing the tuberculous 
nature of the process by the local and general reaction. The diagnosis 



SPECIAL DIAGNOSIS 473 

is easier if the presence of encapsulated ascites can be demonstrated 
by percussion and palpation, because tuberculosis is the most frequent 
cause of that condition. Heredity, emaciation and general weakness 
are in favor of tuberculosis. 

3. Gonorrhea! peritonitis results from the escape of gonococci 
from the abdominal extremity of the tube into the peritoneal cavity, 
and is characterized by acute stormy onset of local symptoms — with high 
fever, the absence of signs of intoxication, and rapid, Gonorrheal 
invariably favorable course. As however these differences Pentomtis. 
are not sufficiently precise for the diagnosis between gonorrheal and 
septic peritonitis, the origin of the peritonitis in gonorrhea of the genital 
organs or in tubal disease must, if possible, be demonstrated. The 
history may give support to the diagnosis if the patient admits a recent 
infection. Gonorrheal infection of the peritoneum more frequently 
leads to circumscribed pelvic peritonitis with adhesions. 

4. Carcinomatous peritonitis * develops in connection with car- 
cinoma of the uterus and ovaries and leads to the production of ascites, 
which is usually freely movable, the eruption of small nodules, and 
fiat adhesions in every portion of the peritoneum; later the intestines 
become adherent and larger nodes are formed in the peritoneum, 
especially in Douglas' space and on the contracted omentum. The 
exudate is easy to demonstrate, but the nodules can be felt only after 
they have attained a certain size. Douglas' space should always be 
carefuU}' examined because multiple nodular formations and adhesion 
of the two layers of the peritoneum, and distinct 'snow-ball crunching' 
on combined examination through the rectum are most frequently 
found in that region. The omentum is accordingly the region where 
metastatic tumors are most frec|uently found. The differential diag- 
nosis from tuberculous peritonitis is often very difficult. If, however, 
large tumors are found in the genitalia, especially with signs of malig- 
nant degeneration or distinct omental tumors or large nodes in Douglas' 
space, the condition is very probably carcinomatosis. But the clinical 
pictures in the two diseases may be so similar that they can barely be 
distinguished by careful inspection at the operation. Cachexia and 
crural edema are more frequently observed with carcinoma. 

Pelvic Peritonitis. 

Pelvic peritonitis is much more common in general, than in diffuse 
inflammation of the peritoneum. It usually begins in the genital organs 
and becomes localized on the peritoneum of the true pelvis and neigh- 
borhood, especially the abdominal walls. It is observed at every stage 

* This form is included under infectious peritonitis, although the virus of carcinoma 
is still unknown . 



474 GYNECOLOGICAL DIAGNOSIS 

from an acute beginning process to the remains of an old thickening 
of the membrane or adhesions. The acute onset of pelvic peritonitis 
is characterized only by intense signs of inflammation of the peri- 
Peivic toneum; later a purulent or serous exudate is produced 

Peritonitis. j^^ ^^^^ ^^^^g pelvis, or tlic inflamed layers of the peritoneum 

become adherent. From a diagnostic standpoint we therefore distinguish 
three clinical pictures; recent pelvic peritonitis, peritonitis 
with exudate, and peritonitis with adhesions. 

I include under the term recent pelvic peritonitis the acute 
stage of exudative peritonitis with adhesions, relapses of pelvic peri- 
tonitis, and the recent circumscribed inflammations that grow around 
Recent Pelvic the individual genital organs. The common diagnostic 
Peritonitis. feature of these forms of inflammation is therefore the 

recency of the process or the formation of inflammatory products. 
Acute perimetritis, perisalpingitis and perioophoritis are concomitant 
conditions. The most important physical sign, on which the diag- 
nosis of this early stage is based, is tenderness on pressure of the 
peritoneum elicited by external palpation of the abdominal walls with 
reflex tension of the abdominal muscles, or from within by palpation 
of those portions of the pelvis that are covered with peritoneum, or 
by displacing the uterus or adnexa. In the acute stage of exudative 
or adhesive peritonitis there may be local signs of irritation in the form 
of slight meteorism, strangury (tenesmus vesicae) and, occasion- 
ally, vomiting and singultus; mild febrile movements are also quite 
common; spontaneous pain in the inflamed peritoneum may be so 
severe that the patient is unable to perform the slightest movements. 
In this stage the diagnosis can hardly be missed, although there are no 
characteristic physical signs and accurate palpation of the pelvic organs 
is impossible. The diagnosis is much more difficult in circumscribed 
processes, when all signs of irritation are absent and only peritoneal 
tenderness is elicited. The distinction between inflammatory and 
nervous pain is often very difficult. In such cases it must be deter- 
mined whether the patient is one of those hyperesthetic women who 
start at the least touch of the abdominal walls as if they were suffer- 
ing from severe peritonitis, and in making an internal examination it 
must be borne in mind that fear, excitement or awkward pressure with 
the finger may simulate peritonitic pain. If, however, local pain on 
pressure is constantly elicited in the same places on careful palpation 
or displacement of the genital organs, which are not in themselves 
painful, a diagnosis of peritonitis may be made even in the absence of 
an inflammatory product; whereas nervous peritoneal pain, whether 
due to hyperesthesia of the peritoneum or marked hyperesthesia of 
the skin such as occurs in lumbo-abdominal neuralgia, is changeable, 



SPECIAL DIAGNOSIS 



475 



dependent upon external influences, and often out of all proportion 
to the degree of pressure employed. 

The diagnosis of pelvic peritonitis is much more certain when 
the process has gone on to the deposition of an inflammatory product 
and produced physical signs. 

The exudate of pelvic peritonitis (pelvic exudate), which owes 
its origin chiefly to infection with streptococci and staphylococci, is an 
effusion of serous, seropurulent or purulent fluid, and most frequently 




Fig. 287. — Pelvic Exudate. P.-F. H- (Original.) Douglas' space contains an exudate as large 
as the fist and broadly adherent to the entire posterior wall of the uterus, which is in retroversion and ante- 
position; the e.xudate is also partly attached to the posterior pelvic wall. 



becomes encapsulated in Douglas' space, uniformly filling the cavity 
if there are no adhesions. The uterus is displaced to the anterior pelvic 
wall so that the vaginal portion is felt immediately behind the sym- 
physis and, if the exudate is extensive, below the upper 
border of the bone ; while the uterine body and adnexa are 
in such intimate contact with the exudate that the bound- 
aries of the latter are often difficult to make out. Behind the uterus 
the exudate is felt as a tumor which completely fills the upper portion 
of the true pelvis, occasionally projects far above the pelvic inlet, and 
is in contact with the anterior abdominal wall to one side or above the 



The Exudate 

of Pelvic 

Peritonitis. 



I 



(7^=^^ 



476 GYNECOLOGICAL DIAGNOSIS 

uterus. The upper half of the posterior vaginal wall is displaced far 
downward, often to within a short distance of the introitus; through 
the vault the lower border of the exudate is felt either round or with 
a blunt edge, depending on the tension to which it is subjected in Doug- 
las' space. In front the exudate is partly in contact with the posterior 
wall of the uterus, usualty as far as the fundus, and behind it is closely 
attached to the anterior sacral wall; while the lateral walls of the pelvis 
are reached only in the case of large tumors (Figs. 287 and 288). The 
roof of the exudate is formed by coils of intestine, hence the upper 
border is inaccessible to the palpating hand and often appears like an 
accumulation of ribbons filled with gurghng gases. In the recent stage 

the consistency of the exudate is 
always fluctuating; or it may be 
soft and yielding or tense and 
elastic, depending on the tension 
to which the exudate is subjected. 
In the neighborhood of the exu- 
date irritative symptoms are 
observed, varying in intensity 
according as the exudate is serous 
or purulent. Thus, with an abscess 
in Douglas' space, the vaginal 
membrane is bluish, soft and 
boggy, with pulsating vessels; 

Fig. 288.— The Same in Cross Section. P.-F. the rectal membrane SWollcU and 

Yi. (Original.) The rectum is displaced far to the ... 

left by the exudate, but not entirely surrounded; the edcmatOUS, SeCretlUg a glairy 

rectal wall bulges toward the lumen. i • i c , i 

mucus which escapes from the 
anus. At the upper circumference of the exudate diffuse areas of thicken- 
ing are found among the coils of intestines. In cases of serous exudate 
these signs of reaction are much more rare and may be wanting altogether, 
A deviation from the above typical findings will be observed when 
adhesions are present in Douglas' space and the exudate collects in 
the lateral pockets of the peritoneal cavity, in front and behind the 
broad ligament or in the vesico-uterine excavation. In such a case 
nothing can be felt through the vagina, and on bimanual palpation 
only indistinct resistance with fluctuation and without distinct outlines. 
Encapsulated collections of serous fluid are freciuently found between 
Adhesion aclhesious, especially in the case of adnexal tumors — 

^^^'^' so-called adhesion cysts. If these cysts are accessible 

to the palpating finger through the os they are felt as a flaccid, cystic 
resistance without any distinct outline; if the fluid is under considerable 
pressure they feel like cystic tumors. Thus I once mistook a collection 
of adhesion cysts as large as a fist for a hydrosali^inx. After diffuse septic 






SPECIAL DIAGNOSIS 477 

peritonitis encapsulated accumulations of pus or serous fluid sometimes 
remain in the upper abdominal cavity. Their presence can be demon- 
strated only if they have attained a certain size and are favorably situated 
for palpation, immediately underneath the abdominal walls. They are 
characterized by a very irregular shape, indistinct outlines and low tension. 

The differential diagnosis between a serous and a puru- 
lent exudate can be made in a case of this kind by noting the reaction 
in the neighborhood. Softening and succulence of the vaginal mucous 
membrane, infiltration of the surrounding structures indicate pus; 
fever is an inconstant symptom and may be absent in old cases. On 
the other hand, a high leukocytosis (between 14,000 and 20,000 according 
to Pankow) is in favor of a purulent exudate. 

Differential diagnosis. A retro-uterine exudate in the recent 
stage is always distinctly fluctuating and can therefore be mistaken 
only for a cystic tumor. The most important among adnexal 
tumors are those which develop low down in Douglas' Differential 

space, especially pedunculated ovarian tumors. As hydro- Diagnosis, 

salpinx is usually situated higher up and more to one side, it is more apt 
to resemble an asymmetrical exudate. A retro-uterine ovarian 
tumor with anteposition of the uterus may be mistaken for a retro- 
uterine exudate only if it is partly adherent to the surrounding struc- 
tures and has lost its sharp contours; but even in cases of this kind 
accurate palpation of the tumor outline is the best means of arriving 
at a diagnosis. In an ovarian tumor it must be possible to feel a tumor- 
wall (Fig. 156), while in the case of exudate the limiting wall is supplied 
by the surrounding organs. The best way to determine this point is 
to make deep palpation from the side between the posterior uterine wall 
and the tumor, noting whether the two structures are distinct or inti- 
mately connected with one another by a broad surface of attachment; 
or by palpating the upper circumference, which in one case is a sharp, 
well-defined outline and in the other an indistinct contour formed by 
intestinal coils. Notable differences can sometimes be felt through 
the rectum. In benign tumors the rectum is only moderately dis- 
placed and possibly somewhat invaginated, while inflammatory pro- 
cesses — if they extend to the subperitoneal connective tissue — surround 
the rectum in the form of a loop. In the case of flaccid hydro- 
salpinx occupying part of the pelvis the diagnosis is more difficult. 
Although, like ovarian tumors, hydrosalpinx has a wall of its own, 
it is much more difficult to demonstrate than that of an ovarian tumor 
on account of its thinness and the much more numerous adhesions 
with the posterior uterine wall and the intestinal coils. If the woman 
can be kept under observation for some time, the pus will be slowly 
absorbed or spontaneously evacuated, and the diagnosis of exudafe is 



478 GYNECOLOGICAL DIAGNOSIS 

established; while a hj-clrosalpinx usualh^ remains stationary, and 
ovarian tumors slowly increase in size. General disturbances and fever 
are in favor of inflammatory processes. 

The greatest difficulties are encountered in the diagnosis between 
exudate and a typical retro-uterine hematocele. The shape and 
situation of the tumor and its broad attachment to the uterus and 
pelvis are exactl}^ the same as in the case of exudate, because the fluid 
blood also collects in Douglas' space and by encapsulation and organi- 
zation of the periphery also becomes intimately adherent to the other 
organs. ' The only difference observed in hjalrosalpinx is in the con- 
sistency. The blood coagulates; the consistency becomes irregular, 
cystic portions alternating with soft masses. If the blood remains fluid, 
the consistency may be exactly the same as that of exudate. As the 
presence of blood causes but slight signs of irritation in the neighborhood, 
the signs resemble those of serous exudate. If the hematocele breaks 
down, however, the inflammatory symptoms in the neighborhood 
increase and the picture of pelvic abscess is produced. In man)^ cases 
the history affords positive data for the differential diagnosis. If it is 
found that the condition was preceded by a short period of amenorrhea; 
if the onset was severe, with frequentty repeated abdominal cramp, 
and pain without fever, the probability is on the side of hematocele 
{ex graviditate tubaria) ; while acute onset with high fever and signs 
of peritonitic irritation point to exudate. Serous exudates usually 
develop without fever or pain. Anemia and a mild degree of jaundice, 
as well as uterine hemorrhages, are in favor of hematocele. The leuko- 
cyte count appears to be a valuable means of distinguishing between 
pelvic abscess and a non-infected hematocele. In the latter the number 
of leukocytes is normal, unless the patient is extremely anemic; but 
once the hematocele breaks down, the leukocytosis becomes very high. 
In cases of serous exudate the difference is less marked. The surest 
means of arriving at the correct diagnosis between hematocele and 
serous or purulent exudate is exploratory puncture. As the 
posterior vault of the vagina only is punctured and no organ is injured, 
aseptic perforation is not followed by any bad results. After careful 
disinfection of the vagina an aspiration needle with a thin canula is 
introduced into the deepest portion of the retro-uterine tumor behind 
the portio vaginalis, under guidance of the finger. But even in these 
cases exploratory puncture should be employed only as a last resort. 

The diagnostic value of exploratory puncture through the 
posterior vaginal vault forms the subject of an essay by Franz, who reports that among 81 cases 
from his clinic in Halle the diagnosis was confirmed in 56; a doubtful diagnosis was rendered 
positive in 5; an erroneous diagnosis corrected in 10; in 6 exploratory puncture was mis- 
leading, and in 4 without result. It appears therefore that exploratory pimcture is not superior 
to other methods of examination, since the 10 successful cases are balanced by 10 failures. 



SPECIAL DIAGNOSIS 479 

That the method even in the simple cases and when performed in a hospital is not without 
danger is shown by the fact that it was followed by severe infection in one case, by mild 
infection in 5 others, while in the 6th death probably was remotely or partly due to the 
exploratory puncture. These results justify my advice that the use of exploratory puncture 
be restricted as much as possible. 

A retro-uterine exudate is less likely to be mistaken for retro- 
flexion of a gravid uterus than for hematocele, because the 
history is not so misleading. The diagnosis is based on the same prin- 
ciples as have been explained in connection with hematocele (see p. 167). 

Peritonitic adhesions represent either the remains of old inspis- 
sated, ruptured, or evacuated exudates, or the product of pelvic perito- 
nitis with adhesions. In the former case they represent thick, brawny 
cicatrizations, with partial obliteration or localized contrac- perUoneai 

tion of individual portions of the peritoneum. In the latter Adhesions, 

case they are membranous bands of variable thickness, which envelop 
the organs or connect them with one another or with the pelvic wall. 

The diagnosis of these inflammatory products is based on the 
direct palpation of brawny, diffuse thickening in Douglas' space, pro- 
ducing complete or partial obliteration of the space with retroposition 
of the uterus. The thickened areas can be felt by pushing the posterior 
vaginal vault upward, or through the rectum. When the uterus is drawn 
forward it brings the anterior rectal wall with it. Localized contractions 
of the peritoneum are recognized by numerous thickenings and want of 
elasticity in the membrane. Genuine peritonitic adhesions are felt as 
membranes or bands connecting those portions of the genitalia which 
are covered with peritoneum, especially in Douglas' space and in the 
neighborhood of the aclnexa. By pushing the vaginal vault forcibly 
upward they may be felt as thin, delicate cords that are easily torn by 
the pressure of the finger and are usually painful. Another sign of 
peritonitic adhesions is the fixation of otherwise movable organs, espe- 
cially the uterus, tubes, ovaries and intestines. If the mobility of the 
uterus in any given direction is abolished, or if it is found impossible 
to elevate a retroflexed uterus, the existence of peritonitic adhesions 
may be inferred, provided the immobility is observed constantly in 
those parts which are covered with peritoneum. If a prolapsed ovary 
cannot be hfted out of Douglas' space, or a normally placed ovary has 
lost some of its normal mobility along the pelvic wall, we have to deal 
with the remains of a perioophoritic inflammation. If immovable coils 
of intestines are constantly found at certain points on a tumor, or per- 
manently occupy Douglas' space, they are probably fixed by peritonitic 
adhesions. The presence of the latter may also be surmised when there 
is local pain on pressure in places covered by peritoneum. If, for 
example, in the case of large ovarian tumors certain areas are constantly 
found to be painful, it is a sign of local peritonitis, and at laparotomy 
circumscribed peritoneal adhesions are usually found in these regions. 



wn 



480 GYNECOLOGICAL DL\GNOSIS 



Diagnosis of Parametritis. 

Parametritis is inflammation of the pelvic connective tissue 

situated between the peritoneum and the levator ani muscle and 

occupying the intervals between the individual pelvic organs which it 

completely surrounds (p. 90). Parametritis also includes 

Definition. . . , . . • n • c 

paracystitis and paraproctitis, or mnammation or 
those portions of the pelvic connective tissue which surround the 
bladder and rectum respectively. Parametritis in the great majority of 
cases begins in the pelvic connective tissue that surrounds the genitaha 
and from that area may spread to more distant layers of connective 
tissue that are continuous with the parametrium, such as the preperi- 
toneal cavity of Retzius and the connective tissue of the iliac bone, 
which is continuous with the retroperitoneal tissue. Conversely, con- 
nective tissue inflammation, originating in distant organs, as paratyphlitis 
or paranephritis, for example, may spread downward to the pelvic 
connective tissue and produce conditions similar to primary parametritis. 
Parametritis occurs in two distinct forms: exudative and 
contracting parametritis (parametritis retrahens). 

1. Parametritic Exudate. 

A parametritic exudate is the product of a tissue reaction which 
follows invasion by microorganisms. 

The organisms concerned are almost exclusively streptococci and staphylococci, 
rarely gonococci and bacterium coli; in isolated cases tuberculosis and actinomycosis have 
been observed. The differences produced in the clinical picture of the exudate by the dif- 
ferent kinds of organisms will be discussed later. 

The tissue reaction results in the deposition of a gelatinous fluid 
in the meshes of the connective tissue and, in the recent stage, repre- 
sents a soft elastic swelling of the affected region, with blurring of the 
outline. After the edema in the surrounding tissue has subsided by 
absorption, and the inflammatory fluid has coagulated, the exudate 
appears in its characteristic form as a hard tumor. As such it persists 
for a long time, and the inspissated contents become more and more 
hard and firm. The exudate may disappear completely by absorption, 
leaving normal, soft connective tissue in its place; but there remains 
a brawny thickening, which leads to the contraction of the tissues and 
uterine displacement. If the exudate continues to spread, the same 
changes take place in successive portions of the connective tissue, 
while absorption goes on in other places. If the exudate breaks 




SPECIAL DIAGNOSIS 481 

down and suppurates; small abscesses are formed in various places, 
which graduall}^ coalesce and produce large collections of pus that 
usually follow a definite path to the outer surface of the body. 

Diagnosis. 

The diagnosis of parametritic exudate is based on the finding of 
a tumor in the pelvic connective tissue presenting certain important 
characteristics, determined by external and internal examination. 

Position. The tumor must occupy a region which contains para- 
metria! connective tissue or one of its processes. The most frequent 
situation is the posterolateral — 

portion of the horizontal layer of ^'■:^::-»^ 

the connective tissue, the tumor 
forming to one side and behind 
the uterus; secondarily a portion 
of the exudate usually spreads in 
the retro-uterine tissue to the 
other side of the pelvis and forms 
a loop around the rectum (Fig. 
289). More rarely the exudate is 
entirely confined to the retro- 
uterine tissue. In such a case 
a retro-utC'rine tumor situated 
almost exactly in the median line fig. 289.— parametritic exudate m the left 

Posterior Quadrant. P,-F. '/i. (Original.) The 
IS produced, the lateral portions or exudate spreads to the otlier side in the retrocervical 
, . -, n , , 1 111 tissue, surrounding and constricting the rectum. 

which are flattened and broken 

up into fibres; while below, the tumor extends into the recto- 
vaginal septum and usually ends in a sharp border opposite the middle 
of the posterior vaginal wall (Fig. 290). Puerperal exudates are often 
situated between the layers of the broad ligament, forming situation of 
large tumors alongside of the uterus and above the pelvic ^^^ Exudate. 
inlet. They frequently extend into the true parametrium and therefore 
cannot be palpated through the vagina; at the sides they approach the 
pelvic wall in the infundibulopelvic ligament (Fig. 291). If the exudate 
is situated in the connective tissue on the iliac bone, a flat tumor is pro- 
duced with broad attachment to the bone and connected with the uterus 
by a broad ligament as by a cord, or even entirely free, so that it gives the 
impression of being an independent tumor. If the extension takes place 
from this point upward, the connective tissue of the lateral and posterior 
abdominal wall becomes involved; while in front the exudate may 
extend above Poupart's ligament and reach the anterior abdominal wall. 
From the parametrium the exudate, after elevating the anterior layer 
of the broad ligament, enters the loose connective tissue which sur- 
31 







482 



GYNECOLOGICAL DLIGNOSIS 



rounds the bladder and the preperitoneal cavity of Retzius (Fig. 292), 
and from that point extends upward in the subperitoneal adipose 
tissue of the anterior abdominal wall. These exudates in the abdominal 
wall do not extend beyond the region of the navel because at this point 
the loose connective tissue between the parametrium and the fascia 
disappears. Nor do they overstep the median line, so that in the main 
they represent flat masses or thickenings limited to one half of the 
anterior abdominal wall. The anterior parametrium, or that portion 




Fig. 290. — Parametritic Exudate in the Rectovaginal Septum. P.-F. %. (Original.) The exudate of 
Fig. 289 shown in median section. It extends to within 4 cm. of the introitus; marked stenosis of the rectum. 

of connective tissue which is situated between the cervix and body, is 
very rarely the seat of exudation. The exudate, when it occurs, forms 
a cord-like tumor extending upward to about the middle of the uterus 
and disappearing on each side of the horizontal layers of the pelvic 
connective tissue (Fig. 293). When suppuration takes place in the 
parametritic exmdate, the pus follows certain definite paths, along 
which the solid exudate also extends. For example, the pus not infre- 
quently escapes from the pelvic cavity through the sciatic notch and 
makes its appearance under the free border of the gluteus maximus 
on the buttocks; occasionally the pus may burrow in the paravaginal 
and paraproctal tissue and make its appearance on the perineum. 



SPECIAL DIAGNOSIS 



483 



The shape of the exudate is exceedingly variable, depending on 
the shape of the layer of connective tissue in which it develops. Wher- 
ever the exudate is limited by peritoneum it is completely spherical; 
while in places where it merges with healthy connective shape of 

tissue it is irregular and diffuse, and the shape of the inflam- *^^ Exudate. 
matory mass is fiat and radiating. When the exudate is in contact with 
organs — the pelvis, uterus or rectum— the latter form a sharp boundary 
and are often enveloped by the exudate. Exudates in the horizontal 
layer of connective tissue are flat 
and diverge widely, especially in the 
lower portion. They surround the 
rectum, descend along the side of the 
vaginal vault, and spread out on the 
pelvic wall. The upper surface of 
intraligamentary exudates, so far as 
it is covered by the separated layers 
of the broad ligament, is perfectly 
round; while the lower portions are 
broadened out and are gradually lost 
in the horizontal connective tissue 
layer. Exudates on the lateral and 
posterior abdominal wall are perfectly 
flat and spread out, while on the ante- 
rior abdominal wall the exudate 
becomes thinner and thinner toward 
the body and ends in a sharp edge; 
below, it gradually becomes broader 
and more massive and is lost in the 
horizontal connective tissue layer. 
Large exudates in the folds of Douglas are also spherical where 
they are covered with peritoneum, while below they are broad. 

The connection of the exudate with neighboring structures is one 
of its most important properties because it is the chief point of distinc- 
tion between exudate and tumor. When the inflammatory process 
reaches the pelvis or one of the organs, it spreads around 
and along the structure into the meshes of connective 
tissue and, as coagulation takes place, a broad, intimate 
union is produced. Exudates in the lateral portion of the 
parametrium have a broad attachment to the lateral pelvic wall (Fig. 
292). The union with the uterus is also extremely intimate in those 
places in which parametrial connective tissue comes in relation with 
the organ. Exudates in the horizontal connective tissue have a broad 
attachment with the lateral and posterior surfaces of the cervix, fre- 




FiG. 291. — Puerperal Intraligamentary 
Exudate. P.-F. %. (Original.) The exudate 
has prevented the normal puerperal descent of 
the uterus; the fundus is midway between um- 
bilicus and symphysis, and the vaginal portion 
at the level of the pelvic inlet. The right broad 
ligament contains an exudate the size of a fetal 
head, leaving the horizontal parametrium free; 
the exudate is broadly attached to the iliac bone. 



Connection of 
the Exudate 
with Surround- 
ing Structures. 



484 



GYNECOLOGICAL DIAGNOSIS 



quently surround the posterior surface, rarel}^ the anterior, and occa- 
sionally encircle the entire structure. Intraligamentary exudates attach 
themselves to the lateral aspect of the uterus, which they also occasion- 
ally surround, and extend to 
the anterior and posterior sur- 
faces (Figs. 294 and 295) after 
separation of the loosely at- 
tached peritoneum. Above, the 
exudate is limited by the 
boundary line between the 
loose and the firm peritoneal 
attachment and therefore never 
reaches the fundus. If the exu- 
date is in relation with the 
vagina, which is usually the 
case posteriorly, the attach- 
ment is so intimate that the 
vaginal wall becomes immov- 
able; when the condition is 
merely a flat infiltration instead 
of a large tumor, one gets the impression that the posterior vaginal 
wall itself is very firm and unyielding. The connection with the 
rectum is the most characteristic of all. On the diseased side the 




Fig. 292. — Pahametritic Exudate in the Left Ante- 
rior Quadrant and Anterior Parametrium. P.-F. 5^. 
(Original.) The exudate has a broad attachment to the 
anterior and left wall of the pelvis, displacing the body to 
the right, and extending between the body and the anterior 
cervical wall to the other side. 




Fig. 293. — Parametritic Exudate in the Right Broad Ligament and Anterior Parametrium. 
P.-F. J^. (Original.) The exudate fills the entire right ligament and extends to the pelvic wall. It forms a 
cord as thick as the thumb, which passes in front of the cervix, between it and the bladder, to the other side of 
the pelvis, where it gradually breaks up and reaches the pelvic wall. The connection of the exudate with the 
uterus in front extends as far as the line which marks the loose attachment of the peritoneum with the organ. 

exudate is intimately attached to the structure and produces a rigid 
semicircle which merges on each side with the fiat exudate; if the 
exudate also involves the retro-uterine tissue and the other quadrant, 
the ring around the rectum becomes complete and in contracting 



SPECIAL DIAGNOSIS 



485 



produces stenosis of the lumen, so that the finger can only be intro- 
duced with difficulty. In order to follow its connection with the rectum, 



the finger must be inserted above the fold of Kohlrausch. 



The mucous 




Fig. 294. — Parametritic Exudate Occupying the Left Broad Ligament and Iliac Bone. P.-F. 
J^. The horizontal layer of connective tissue is not involved and the exudate is broadly adherent to the 
iliac bone; the median portion of the exudate is readily movable with the uterus. 

membrane is immovable on the exudate. For the changes produced 
by the attachment of the exudate to the bladder see page 496. 

The mobility of parametritic exudates depends on their con- 
nection with the pelvis. The more extensive the attachment, the more 
immovable the tumor; while, 
on the other hand, the median 
portion of the exudate may 
retain a high degree of mobility 
(Fig. 294). Intraligamentary 
exudates which are no longer 
attached to the pelvis may 
exhibit a very great degree of 
mobility with the uterus. 

The consistency is not 
characteristic and may vary 
from succulence to bony hard- 
ness. Recent exudates are soft, 
elastic, and somewhat yielding 
to the touch, but within a few 
days the succulence subsides and 
the exudate grows hard and unyielding. The hardness rapidly increases, 
the exudate gradually becoming more and more firm and cicatricial, 

Pain has no diagnostic value. On the contrary, large parametria! 
exudates are practically painless, except when parametritic and tuba] 
tumors are associated. 




Fig. 295.— The Same in Cross Section. P.-F. %. 
Broad attachment to the left aspect of the uterus. The 
exudate surrounds and causes separation of the posterior 
cleft of the ligament. 



486 GYNECOLOGICAL DIAGNOSIS 

Certain data obtained from the history are important. Para- 
metritis always results from infection; hence a cause for infection 
should be sought in parturition, abortion, operations on the genitalia, 
intraligamentary uterine manipulations, or some injury 
during menstruation. In doubtful cases the diagnosis may 
find support in a positive statement of this kind, especially if a time 
relation can be established between the disease and the exposure to 
infection. The mode of onset with chill, followed by a febrile course, 
may establish the inflammatory nature of the condition; but it must be 
remembered that a negative history in this respect does not exclude 
infection, because the fever may be so short that the woman pays no 
attention to it. 

Keeping the patient under observation may also help to make 
the diagnosis. Fever indicates an inflammatory infection. In para- 
metritis it is usually distinctly remittent and, if protracted, 
points to further extension of the process. Rapid extension 
during the recent stage and gradual diminution in the size of the tumor 
during the stage of absorption indicate an exudate. The general 
condition and the symptoms furnish no information of any value. 

Differential Diagnosis. 

Owing to the frequency of parametritic exudates and the great 
variety of physical signs to which they give rise the differential diag- 
nosis is extremely important. Exudates may be mistaken for any kind 
of hard tumor in the neighborhood of the uterus. 

Inspissated exudates, especially the spherical, intraligamentary 
masses with broad attachment to the uterus, may closely resemble 
subserous myomata. The distinction is made by the outline, 
Subserous whlch in the case of myoma is everywhere round except 

Myomata. ^^^ ^^iQ pediclc; wliilc a parametritic exudate is only round 

above, where it is covered by two layers of the broad ligament (especi- 
ally when there is no complicating perimetritis with intestinal adhesions), 
and below and to each side flattens out with the lateral spreading of 
the connective tissue and is firmly attached to the pelvic wall. Again 
the connection between the uterus and a myoma is always more or less 
pedunculated, although the pedicle may appear broad; whereas exu- 
dates are much more intimately attached to the uterus, surround the 
organ after causing separation of the loosely attached peritoneum, 
and come in close contact with the anterior or posterior wall. Often 
the diagnosis is cleared up by discovering continuations of the exudate 
in the rectovaginal septum and other portions of the pelvic connective 
tissue. In doubtful cases a rectal examination should be made. In the 
case of myoma the lower portion of the tumor is round and distinctly 



SPECIAL DIAGNOSIS 487 

separated from the pelvic wall, while in exudate the attachment to the 
pelvic wall is more easily recognized through the rectum. When a 
myoma and an exudate are present at the same time, the diagnosis is 
very difficult. In the case of intraligamentary exudate the difficulty 
is that the inflammatory mass does not involve the horizontal connective 
tissue and the characteristic broadening of the lower portion is not 
present; the diagnosis in such a case may often be based merely on the 
presence of a few adhesions. Mobility is not necessarily a sign of 
myoma, as intrahgamentary exudates that do not extend as far as the 
pelvic wall may be movable with the uterus; on the other hand, exudates 
limited to the horizontal connective tissue differ from myomata by the 
fact that they are immovable. 

Intraligamentary peritoneal exudates are much less likely to be 
mistaken for myomata because the contents are fluid and remain fluid 
for some 'time; but ultimately they become inspissated, the consist- 
ency more firm, and the outline at the same time irregular, thereby 
greatly assisting the diagnosis. In the differential diagnosis between 
myoma and intraligamentary peritoneal exudate roundness of contour 
is always in favor of myoma, particularly at the upper portion of the 
tumor, where the adherent coils of intestine produce a very irregular 
boundary in the case of exudate; while below, where the exudate 
is covered by the peritoneum of Douglas' space, the outhne may 
also be round. 

The symptoms are practically of no value in the differential diag- 
nosis between myoma and exudate. Even pain may be completely 
absent in the case of an old exudate. On the other hand, the statement 
that the disease began acutely with fever is of considerable diagnostic 
value and points to exudate. Keeping the patient under observation 
may assist greatly in the differential diagnosis between these two con- 
ditions. A myoma retains its size or increases very little; at all events 
it never becomes smaller or at most. very slowly under certain favorable 
conditions, while an exudate may disappear altogether in a short time, 
especially if measures calculated to promote absorption are employed, 
or it may diminish considerably in size, or the shape may be altered 
in course of time and the exudate is easily recognized by the covering 
and the connection with the neighboring organs. Hence in all doubtful 
cases a second examination at the end of about two months will help 
to establish the diagnosis. 

The leukocyte count does not always furnish the desired informa- 
tion. Although myoma by itself never produces leukocytosis, and the 
sign is never absent in the recent and subacute stages of pelvic exudate, 
yet an old exudate, which is more likely to be mistaken for a myoma, 
has no influence on the number of leukocytes. 



488 GYNECOLOGICAL DIAGNOSIS 

Fritsch reports a case that illustrates the importance of this differential diagnosis. — - 
"Many years ago, " lie says, "I did an ovarectomy on a patient who had come a long distance on 
account of a myoma as large as a fetal head with severe hemorrhage. The patient had no fever 
and left the hospital cured. Ten weeks later severe fever began and I discovered a parame- 
tritis at the usual site above Poupart's ligament; the pus was discharged and the tumor disap- 
peared. I had mistaken an old exudate for a myoma and the ovarectomy was entirely useless. " 

The differential diagnosis between parametritic exudate and 
pyosalpinx is often exceedingly difficult. The two conditions have 
often been confounded on account of the similarity in the history, 
symptoms and physical signs. Even at the present time there is no 
doubt that most cases of pyosalpinx are mistaken for exudates by 
inexperienced examiners; indeed it may tax all our diagnostic resources 
to decide between an exudate and a tubal tumor, or to determine 
in a case of exudate whether the tube is also diseased. The con- 
sistency is obviously no criterion, as pyosalpinx, unless it contains a 
very large quantity of pus, does not give fluctuation and feels quite as 
hard as an exudate; on the other hand, the position of the tumor with 
reference to the uterus is important. Exudates in the main occupy a 
deeper position alongside of the cervix and sometimes crowd the vaginal 
vault downward. Even when they are situated in the broad ligament, 
alongside of the body, they usually involve the lower portion of the 
body and spread in the horizontal connective tissue. When, on the 
other hand, the tumor is situated high up alongside of the fundus and 
at the posterior wall of the body, it is probably a case of tubal disease. 
Exudates are usually flat and diffuse, while tubal tumors are round, 
particularly above, and even when associated with exudates usually 
present a roundness somewhere. On examining from below or through 
the rectum it is difficult to distinguish between the two conditions, 
for the reason that it is precisely below the base of the pyosalpinx 
that exudates are most likely to accumulate. Pus tubes are usually 
more movable with the uterus than exudates. If a tumor of the above- 
described properties is found on both sides of the fundus, bilateral 
tubal disease is very probable. 

Hematomata in the pelvic connective tissue give rise 

to physical signs very similar to those of an exudate, and a positive 

distinction is not always possible. In the broad ligament the effusion 

of blood in the pelvic connective tissue, which usually 

Hematomata 

in the Broad results from a rupture of a large vein or a gravid tube. 

Ligament. . . i p ^^ 

burrows and lacerates the connective tissue and tollows 
up the processes in a manner very similar to that of an exudate. 
The most common seat of hematoma is alongside of the uterus 
in the broad ligament. From here it extends to the pelvis, often 
surrounding the posterior surface of the uterus (Fig. 296), and 
enters the parametrium on the opposite side. Large hematomata 



I 



SPECIAL DIAGNOSIS 



489 



spread out on the iliac bone or produce tumors above the pelvic inlet. 
At first the consistency is soft and elastic, but coagulation soon takes 
place and the tumor becomes harder, although never uniformly firm 
like that of an exudate. Fluid and solid portions alternate, and occasion- 
ally the crunching of blood clots can be detected. The connections 
between a hematoma and the pelvis and uterus are not usually so extensive 
and intimate as in the case of exudate; hence the chief distinction 
between hematoma and exudate are the consistency, which is always more 
uniformly firm in exudate, the shape, which in hematoma is generally 
speaking round, rarely with long processes extending into the adjoining 
tissue, while exudates are usually flatter and more diffuse and occasion- 
ally have broad connections with adjoining organs. In old hemato- 




FiG. 296. — Hematoma IN THE Right Broad Ligament. P.-F. %. (Original.) The tumor is broadly 
attached to the right lateral aspect of the uterus and has produced bulging and partial separation of the 
posterior layer. The consistency is alternately hard and soft; the horizontal connective tissue is not involved. 
— Four weeks previously the woman had a fall, followed by irregular hemorrhages. The diagnosis was 
confirmed by the aspiration of blood. 



mata the surface is often round; in exudates these changes occur later 
and are always less distinct. In some cases the physical signs are not 
sufficiently definite for a differential diagnosis, particularly as hema- 
toma is usually accompanied by inflammatory thickening of the con- 
nective tissue. In these cases the clinical history must be consulted. 
Exudates usually begin acutely with fever and possibly with chills; 
while hematoma as a rule owes its origin to traumatism, particularly 
during menstruation; fever is absent; and, on the other hand, long 
continued hemorrhages frequently occur, the patient complaining of a 
sense of tension. Anemia, occasionally associated with a slight degree 
of jaundice, is usually present if the hematoma is large. 

The leukocyte count may decide the diagnosis. Leukocytosis is 
always absent in cases of hematomata unless the patient is very 
anemic; while it is present in exudate, although somewhat variable. 



■n 



490 



GYNECOLOGICAL DIAGNOSIS 



Perit5'phlitic and paraty phlitic exudates of long standing 
may be confounded with parametritic exudates on the ihac bone, espe- 
cially if they extend deep down into the broad ligament and approach 
the uterus. Since, on the other hand, the connection between 

Peritj'phUtie and 

Paratypiiiitic the utcrus and a parametritic exudate that has spread 
upward to the iliac bone maj^ be absorbed and disappear, 
the physical signs in the two conditions may be quite similar. As a rule, 
however, the main portion of the mass is found on the iliac bone in cases 
•of paratyphlitis, while the median portion of the broad ligament is 
entirely free and soft (Fig. 297). Ferity phlitic exudates are also char- 
acterized b)^ their softness and the indefinite character of their upper 
contour toward the abdominal cavity, where they are covered with the 




Fig. 297. — Paratyphlitic Exudate. P.-F. %. (Original.) Tumor as large as the fist, firmly ad- 
herent to the iliac bone and extending somewhat into the pelvis. The tumor is separated by a considerable 
interval from the uterus. At the periphery the consistency is very hard; but above, where the tumor is covered 
■with intestine, it is soft. 



cecum, and by their dull tympanitic note. Faratyphlitic exudates 
envelop the cecum, while parametritic exudates are more apt to lie 
flat on the iliac bone. In the cases of perityphlitis there is a history 
of intestinal symptoms, meteorism, colic, long continued constipation, 
especially at the beginning, and numerous relapses of acute inflammation 
with similar symptoms. If the formation of the exudate can be observed, 
it will be found that the cecum is the starting point of the localized 
tenderness on the iliac bone. Here the exudate first begins to form, 
while the immediate surroundings of the genitalia are quite free. 

Carcinomatous infiltrations of the pelvic connective tissue 
such as follow carcinoma of the uterus, vagina, ovaries, bladder or rectum 
Carcinomatous produce practlcally the same physical signs as exudates in 
Infiltration. ^^iQ same regions. In both conditions the connective tissue 
contains hard masses, producing circumscribed or extensive tumors in 
the parametrium itself or in the connective tissue around the bladder and 



SPECIAL DIAGNOSIS 491 

rectum. Whenever an infiltration is directly continuous with the 
carcinomatous focus that can be felt through the vagina, or develops 
underneath an ovarian tumor with the suspicion of malignancy, the 
carcinomatous nature of the infiltration itself will at once suggest itself. 
Not so, however, in the case of carcinoma of the bladder and rectum, 
because these organs are not examined routinely when there are no 
symptoms. As a rectal cancer spreads into the tissue between the 
rectum and posterior wall of the cervix, it produces a tumor at the 
exact site of a retrocervical exudate, and I have not infrequently seen 
a rectal cancer mistaken for an exudate until the case was cleared up 
by finding a primary focus or by a rectal examination. 

Case 29. — Mrs. M. came here from Russia because one physician told her that she had 
a tumor underneath the uterus and another diagnosed a retroflexed uterus wliich he desired 
to straighten. Physical signs: tlxrough the posterior vaginal wall there is felt a liard tumor, 
somewhat broader than the uterine body, and broadly attached to the cervix, in close rela- 
tion with the vaginal wall, practically immovable, and attached to the pelvic wall. Retro- 
flexion is excluded at once because the small senile body is felt in front of the tumor; but 
rectal examination reveals an extensive, chiefly periproctal carcinoma, which has spread 
in the retro-uterine parametrium as far as the cervix. The starting point is a tumor in 
the posterior parametrium, wliich represents a recurrence after extirpation of bilateral 
carcinomatous ovarian tumors. 

Similar conditions are found in the parametrial tissue, where the 
carcinoma breaks through the bladder wall. 

The diagnosis may be difficult in cases of recurrence, when the 
primary focus is absent and the history of a previous operation suggests 
an old inflammatory focus. If a correct diagnosis cannot be reached by 
demonstrating a connection between the tumor and a primary focus, 
one must judge by the properties of the tumor. Carcinomatous tumors 
have a hard, cartilaginous consistency; while exudates are fibrous and 
firm. In carcinoma there is a tendency to concentric enlargement, 
the surface is uneven, the outline more round, and there are no flat 
processes. Spontaneous neuralgic pain, cachexia and edema of the legs 
occur only in carcinoma. 

The differential diagnosis between perimetritic and para- 
metritic exudate is often exceedingly difficult and may be impos- 
sible even to the keenest diagnosticians because the two conditions are 
frequently combined. There are, however, a few points of peritonitic 

distinction which make the differential diagnosis possible Exudate. 

in most cases. Laterally situated tumors usually belong to the connec- 
tive tissue, while median tumors situated behind the uterus belong to 
Douglas' space. Hence retro-uterine exudates, which may originate 
either in Douglas' space or in the retro-uterine cervical parametrium, 
are the only conditions that are likely to give rise to mistakes. The 
displacement of the uterus indicates the position of the exudate. 



492 GYNECOLOGICAL DIAGNOSIS 

Marked lateropositions indicate peritonitic exudates on each side of 
the uterus; anteposition suggests tumors in Douglas' space or in the 
retrocervical tissue. The parametritic exudate develops underneath 
Douglas' space and is therefore on the whole somewhat lower down 
and nearer the posterior vaginal wall; as a result the vaginal wall is 
firmly attached to the tumor and immovable, whereas simple exudates 
in Douglas' space, provided the intervening connective tissue is free, 
retain a certain degree of mobility. The inferior contour of the tumor 
is of diagnostic value. In the case of peritonitic exudates it is round 
or oval, corresponding to Douglas' space, and sharply defined; whereas 
retro-uterine connective tissue exudates are continued downward into 
the rectovaginal septum and accordingly have a conical lower extremity. 
They also extend further down than exudates in Douglas' space and 
more to one side, as far as the pelvic wall. The most important point 
in my opinion is the relation of the exudate to the rectum. As the 
rectum is extraperitoneal at the level of Douglas' space and surrounded 
only by the paraproctitic connective tissue, a tumor in Douglas' space, 
whether it be an exudate or a hematocele, merely displaces the rectum 
to one side without surrounding it. On the other hand, a parametritic 
exudate surrounds the rectum, causing a circular constriction, and is 
immovably attached to the mucous membrane. The only way to 
recognize these different conditions is by a rectal examination. If the 
tumor merely causes bulging of the rectal wall on one side and crowds 
the rectum over to the pelvic wall, while the muicous membrane remains 
movable, the condition is usually an exudate in Douglas' space; but 
if the tumor surrounds the rectum like a ring and causes a general 
narrowing, or the anus is represented by a round hole which looks as 
if it had been punched out, and the membrane is immovable, the prob- 
abilities are in favor of a parametritic exudate. The relation of 
the tumor to the posterior wall of the uterus may decide the diagnosis. 
The exudates of pelvic peritonitis know no boundaries and are attached 
to the posterior wall of the uterus as far as its peritoneal covering — 
that is, up to the fundus and beyond; while an extraperitoneal exudate 
ceases at the boundary line between the loose and firm attachments of 
the peritoneum and leaves the upper half of the body free. The con- 
sistenc}'' is characteristic unless the condition is very old. Peritonitic 
exudates are usually soft, cystic and fluctuating, while parametritic 
exudates early become hard and unyielding. In cases of old, inspis- 
sated exudates the distinction is more difficult. With regard to the 
clinical course, it must be stated that peritoneal exudates are found 
to be more frequently accompanied by vomiting, meteorism, and 
spontaneous pain; whereas these symptoms, especially the pain, are 
usually absent in parametritis. 



SPECIAL DIAGNOSIS 



493 



Diagnosis of Certain Special Conditions. 

The prognosis in parametritic exudate depends on whether the 
exudative process is arrested and the exudate absorbed, or suppura- 
tion takes place because the microorganisms present are particularly 
virulent or the general and local powers of resistance are not sufficient. 
As surgical intervention becomes necessary unless the pus spontaneously 
finds its way to the surface or into a hollow organ, the physician in 
charge of the case must decide the following questions: 

1. "Whether the exudate is being absorbed. 

2. Whether suppuration has taken place. 

3. Whether perforation is impending or has already occurred. 

In most cases the question can be solved by a careful examination 
or by keeping the patient under observation. 




Fig. 298. — Intraligamentary Parametritic Exudate in Process" of Absorption. P.-F. H- 
(Original.) The main mass of the exudate still occupies the middle of the ligament; the connection with the 
uterus is somewhat thinner, and the attachment to the pelvic wall has disappeared e.xcept for a thick cord in 
the infundibulopelvic ligament. 

Absorption can be determined objectively by certain changes in 
the shape of the exudate. As it is always more active at the periphery 
and in the thinnest portions, the exudate contracts toward the main 
mass, which is always the last to undergo absorption, that is to say, 
toward the pelvic wall or, in the case of intraligamentary exudates, 
toward the uterus. Again, the tumor may be divided into several 
portions by absorption of the connecting bridges of tissue. Absorption 
causes a tendency to increase the cavity of the vagina by drawing the 
vaginal vault upward. Through the rectum firm constrictions are felt 
instead of a bulging. As absorption begins at the periphery, the processes 
in the tumor are the first to retract, causing disappearance of the more 
slender connections with the individual organs, while the more robust 
masses of infiltrated tissue at first persist; as a result exudates in the 
horizontal portion of the parametrium may lose their connection with 



494 GYNECOLOGICAL DIAGNOSIS 

the uterus and have a broad, flat, triangular area of contact with the 
pelvis, while the median portion of the pelvic connective tissue is al- 
ready free. If absorption continues, the exudates retract more and 
more from the pelvic wall and simulate pelvic anomalies, such as 
obliquely contracted pelvis, exostoses, and pelvic tumors. Less fre- 
quently the connection with the pelvis is the first to disappear, and the 
exudate retracts toward the uterus. This is rather more frequent in 
cases of intraligamentary exudates (Fig. 298), which often appear as 
round tumors on the lateral wall of the uterus and simulate myomata. 
Parametritic exudates on the iliac bones or in the abdominal walls 
lose their thin connection with the uterus, and it becomes difficult to 
demonstrate their origin in parametral tissue. The patient's general 
condition during absorption is usually good. The woman looks well, 
although somewhat debilitated; the appetite is good, and there are no 
local symptoms. Fever is usually absent altogether, although slight 
elevations of temperature may occasionally be present. 

Suppuration of the exudate causes small immovable foci. These 
gradually coalesce and form^ in the interior of the exudate large and 
small pus foci, which gradually cause further liquefaction of the tissue 
Suppuration of ^ud rcacli the surface. So long as the suppuration is con- 
the Exudate. fined to the interior of the exudate it does not betray itself 
by any open change. Fluctuation is absent in this stage because the 
focus is surrounded by thick, hard masses of tissue; occasionally a 
slight degree of sensitiveness on deep pressure is present, and the 
hyperemia in the adjoining mucous membrane is increased. 

The diagnosis of this stage of suppuration is based chiefly on the 
general condition. The patient emaciates, becomes weak, loses her 
appetite, and looks pale and faded. These symptoms are all due to 
the absorption of toxins. Fever is almost always present. As recent 
exudates properly treated rarely suppurate primarily, the fever usually 
falls after from 6 to 10 days and, if it returns after an afebrile interval 
of variable length and exhibits a distinct remittent and intermittent char- 
acter, it is suggestive of suppuration. Primary suppuration is rare; but if 
the tumor persists over two weeks and is not explained by the further 
spread of the exudate, suppuration is very probable. The leukocytosis 
which accompanies suppuration is a valuable diagnostic sign. 

In 24 cases of simple parametritic exudates in my service the leukocyte counts were: 

In 12 cases of purulent exudates in wliich the presence of pus was demonstrated by incision 

or perforation, the number of leukocjd;es was from 11,500 (minimum) to 34,000 (maximum). 

The highest figures showed the following distribution: 

to 10,000 leukocytes None. 

10,000 to 20,000 leukocytes 6 times. 

20,000 to 30,000 leiikocytes 4 times. 

30,000 to 40,000 leukocytes Twice. 



SPECIAL DIAGNOSIS 495 

The lowest figures (in cases counted more than once) were distributed as follows: 

to 10,000 leukocj^es None. 

10,000 to 20,000 leukocytes 8 times. 

20,000 to 30,000 leukocytes Once. 

30,000 to 40,000 leukocytes None. 

Hence the leukocyte count never falls below 10,000 when suppuration is present; it 
exceeds 20,000 in about half the cases; and may in any case fall below 20,000, 

In 12 cases of exudate in which suppuration was excluded by the occurrence of 
complete absorption, the leul?:ocjrte count was from 7000 (minimum) to 24,800 (maximum). 

The highest figures show the following distribution: — 

to 10,000 leukocytes Once. 

10,000 to 20,000 leukocytes 9 times. 

20,000 to 30,000 leukocytes Twice. 

30,000 to 40,000 leukocytes None. 

The lowest figures (in cases counted more than once) were distributed as follows: 

to 10,000 leukocytes Once. 

10,000 to 20,000 leukocytes 4 times. 

20,000 to 30,000 leukocytes None. 

30,000 to 40,000 leukocytes None. 

Hence in exudates that do not go on to suppuration the leukocj'tes never exceed 30,000 
(very probably 25,000); they rarely rise above 20,000; and usually fluctuate between 10,000 
and 20,000. Finally a normal count of leukocytes is rarely observed. 

The following diagnostic conclusions may be deduced from my blood counts: Suppura- 
tion is certainly present if the leukocji^es number 30,000, and very probable if they are as 
high as 20,000. With a leukocytosis of from 10,000 to 20,000 suppuration is quite as prob- 
able as absorption. A leukocyte count of less than 10,000 excludes suppuration; hence 
leukocytosis is a positive sign only when the number obtained is either very high or very low. 
It is almost needless to say that in interpreting leukocytosis all other conditions wliich tend 
to increase the number of leukocytes, such as a recent pucrperium, anemia and the like, and 
all phj'siologic causes must be excluded. It must also be remembered that in the case of 
recent exudate a great increase of leukocytes merely represents the reaction to the infec- 
tion and does not at that early period indicate suppuration. Finally, even a moderate 
leukocytosis, if it persists, is more or less suggestive of suppuration. 

Leukocytosis is particularly valuable in the afebrile cases. Among my cases of exuda- 
tions that were undoubtedly suppurative, one had a normal temperature with a leukocyte 
count of 13,000 and in another, in which the temperature rose to 38° C, the leukocytes 
numbered 22,000. In one case in which the elevation was moderate and did not positively 
indicate suppuration, the diagnosis was decided by a leukocyte count of 34,000. 

Hence within certain limits the leukocyte count is a useful aid in 
the diagnosis of suppuration of a parametritic exudate. 

Rupture of the Exudate. If the pus accumulates in the exu- 
date and causes hquefaction at the periphery, rupture to the outside 
takes place, the pus following the shortest path along the line of least 
resistance through the neighboring connective tissue. There are accord- 
ingly a number of characteristic sites of rupture for the various situa- 
tions of the exudate. An exudate on the iliac bone ruptures above 
Poupart's ligament. The same site is selected by exudates situated 
high up between the layers of the broad ligament, which have a tendency 
to elevate the anterior layer. Exudates situated posteriorly in the 



496 GYNECOLOGICAL DIAGNOSIS 

parametrium rupture into the rectum, or rarety on the buttock, at the 
lower edge of the gluteus maximus, reaching that point through the 
great sciatic notch. Exudates in the anterior paravesical tissue usually 
rupture into the bladder; while exudates in the retrocervical tissue 
rupture into the vagina or sometimes on the perineum, which they 
reach by traveling downward along the vagina. 

During the preparatory stage of rupture certain changes take 
place in the affected organs which make the diagnosis of impending 
23erforation possible. 

Rupture through the abdominal walls produces the 
symptoms of simple subcutaneous abscess, with reddening of the skin, 
bulging and fluctuation; before the appearance of these symptoms 
gaps (lacunae) in the tissue may be palpable. 

Rupture through the rectum is usually preceded for a few 
days by constant tenesmus and the discharge of an abundant glairy 
mucus. At this time the rectal mucous membrane is tensely stretched 
by the bulging exudate, swollen and edematous, with all its folds obliter- 
ated, and at one point the exudate appears soft and impressible. 
Rupture is immediateh' followed by evacuation of a large quantity of 
pus, and later the discharge continues in small quantities mixed with 
feces. The opening is often so small and fistulous that it cannot be 
felt and may be recognizable only by its edges or as a minute retraction. 

Rupture througli the vagina is generally preceded by a marked 
bulging of the posterior wall, which is livid and feels soft and succulent. 
After evacuation of the pus the tumor collapses and the opening often 
conceals itself among the folds of the posterior vaginal vault, where 
it is recognized later in the speculum by the escape of the pus. 

Rupture into the bladder reveals itself by very striking 
changes in the bladder wall. Exudates in the neighborhood of the 
bladder cause a bulging of the bladder wall, which ma}^ reduce the lumen 
to a mere slit. At first the prominence is covered by smooth mucous 
membrane; but as soon as the inflammation approaches the bladder wall, 
it produces circulatory disturbances and the mucous membrane is thrown 
into folds of normal color. In some cases the folds become edematous, 
swollen, and covered with small vesicles, due to separation of the epi- 
thelium. The vesicles are transparent and produce remarkable cystoscopic 
pictures (Fig. 299). Kolischer aptly calls it bullous edema. 

Case 30. — Mrs. L. On the left side, in close contact with the bladder, is a hard tumor 
about the size of the fist, intimately attached to the left wall. Cystoscopy shows an other- 
wise normal vesical mucous membrane and striking changes in the part immediately adjacent 
to the exudate. The wall bulges toward the interior of the bladder, and the mucoios mem- 
brane is thrown into thick parallel folds; a few of these folds have a vitreous, translucent 
appearance and are covered with small, transparent vesicles. The mucous membrane is pale 
and in some places covered with small petechise. 



SPECIAL DIAGNOSIS 



497 



"When rupture takes place, the pus is discharged with the urine, 
first in large quantities and later only as a sediment. The cystoscopic 
image changes accordingl}'. Either a large hollow with a ragged edge, 
or a small fistulous opening at the apex of a prominence, discharging 
a small stream of pus (Fig. 300), is seen. Before and after the abscess 
breaks the patient complains of violent bladder symptoms. 

The diagnosis of various kinds of parametritis with reference 
to the microorganisms which produce them, and certain peculiarities 
depending upon accidental causes, is not unimportant because it has a 
considerable influence on the prognosis. 

Septic puerperal parametritis, due to infection with 
streptococci and staphylococci, is characterized by a marked tendency 




Fig. 299. — Mucous Membrane op 

THE BL.A.DDER IN RUPTURE OF AN EXU- 
DATE. The mucous membrane is thrown 
into folds and covered with bullous 
edema. (Modified after Zangemeister.) 




Fig. .300. — Cystoscopic Picture of 
AN Exudate that has Ruptured into 
the Bladder. On the right wall, which 
projects into the lumen of tlie bladder, 
there is a spherical prominence, from 
the conical ape.x of which pus is dis- 
charged. (Modified after Zangemeister.) 



to spread, which is made possible b}^ the softening of the tissue and 
abundant production of tissue juice. Extensive exudates result, locaHzed 
preferably in the broad ligament, and extending from that situation 
to the iliac bone. Under suitable treatment the tendency to suppuration 
is slight; in most cases rapid and complete absorption takes place. 

Septic non-puerperal parametritis is rarely localized 
in the broad ligament and on the iliac bone. The exudate is usually in 
the immediate neighborhood of the organ or wound from which it origi- 
nated. There is much less tendency to extension, and the exudate is 
accordingly smaller. Suppuration is much more frequent than in the 
puerperal form. Absorption occurs later, runs a slower course, and is 
rarely complete. 

Gonorrheal parametritis has the least tendency to spread. 
The exudates are usually small and run a slow course. They cannot 
be distinguished from the preceding by palpation, but absorption is 

32 




498 GYNECOLOGICAL DIAGNOSIS 

very slow and incomplete. The diagnosis of gonorrheal parametritis 
can be made only by the association with pyosalpinx and by demon- 
strating the existence of gonorrhea in the genital organs. 

II. Parametritis Retrahens. 

Parametritis retrahens is a chronic inflammation of the pelvic 

connective tissue which at the very outset manifests thickening and 

cicatricial contraction. It is localized almost exclusively in 

the posterior portions of the parametrium, especially in the- 

two folds of Douglas (posterior parametritis). There is rarely 

any tendency to spread, although the adjacent connective tissue and 

that of the infundibulopelvic 
ligament are frequently attacked 
along with the folds of Douglas. 
Displacement of the uterus, due 
to traction on the cervix, is a 
constant result of this form of 
parametritis and is the most 
prominent change observed by 
palpation. In bilateral parame- 
tritis retrahens the uterus is in 
retroversion; if the process is 
confined to one side, or at least 
one side is chiefly affected, the 
Fig. 301.— paeametritis Retrahens. p.-f. m. cervix is displaced backward to 

(Original.) The right fold of Douglas and the con- 
nective tissue in front of it are contracted, and the the slde of tlie lesloU wltll tllC 
cervix is accordingly displaced to the right. i , • f> i , • r , ^ 

production or lateroversion oi the 
uterus and rarely torsion. If the connectivet issue in the infundibulo- 
pelvic ligament is attacked, the ligament contracts and the ovary is 
fixed to the pelvic wall. I have designated this condition para- 
oophoritis. In rare cases the entire horizontal layer of connective 
tissue contracts and there is atrophy of the genital organs (para- 
metritis atrophicans, Freund, Sr.). 

Diagnosis. The first thing that is noticed in bimanual examination 
is the displacement of the uterus. If it is found that the uterus 
is also fixed in its abnormal position, it must be determined whether 

the fixation has taken place in the body or in the cervix. 

In uncomplicated parametritis retrahens Douglas' space- 
is entirely free and the body is movable in all directions; but if the 
posterior vaginal vault is pushed upward and brings the cervix forward, 
we find the structure fixed either posteriorly or on one side (Fig. 301), 
and the stretching of the adhesions causes pain. The direction in which 
the movement of the cervix is impeded and painful will indicate the 





^C^ 



SPECIAL DIAGNOSIS 499 

seat of the infection. The parametrium on the affected side is very much 
shortened and thickened, in recent cases somewhat doughy and swollen, 
and, when the process has existed for some time, tense and fibrous. The 
vaginal vault is often quite unyielding, as if it also were infiltrated. In 
typical cases of double posterior parametritis we find the 
entire posterior vaginal vault tense and, if the folds of Douglas are put 
on a stretch with the internal fingers after pushing the vaginal portion 
forward and at the same time forcing the vaginal vault upward, two 
rigid cords uniting at an acute angle behind the cervix are distinctly 
felt. These cords are felt very much more easily by introducing the 
finger high up through the rectum, especially under anesthesia; they 
appear as tightly stretched folds that come together behind the cervix, 
and are usually joined in front by several diffuse adhesions. The diag- 
nosis of posterior parametritis is much more easy if the examination 
is made through the rectum. In para-oophoritis the ovary is found 
attached to the pelvic wall by a single cord of the contracted infundibulo- 
pelvic ligament, leaving a certain degree of mobility; traction on the 
contracted ligament causes pain. Quite often both folds of Douglas 
and both infundibulopelvic ligaments are diseased, probably as a result 
of the simultaneous extension of chronic inflammatory processes from 
the uterus to these four lymphatic regions. In these cases four charac- 
teristic painful zones are present — in the two folds of Douglas and in 
the tissue between each ovary and the pelvic wall. 

When the entire mass of pelvic connective tissue undergoes cica- 
tricial contraction, the entire horizontal layer of connective tissue is 
tense and fibrous, and often as hard as a board. The uterus is displaced 
somewhat upward and completely fixed. It appears small and atrophic 
(parametritis atrophicans). 

In exudative parametritis after perforation, evacuation or incom- 
plete absorption, cicatricial brawny thickening of the connective tissue 
may remain and cause displacement of the uterus; but the adhesions 
are not so strictly limited to the posterior quadrants and the two folds 
of Douglas, being found wherever there is exudate. They are also less 
cord-like, more flat, diffuse and usually quite hard and unyielding^ 
occupying large portions of the parametrium. 

The diagnosis of this exceedingly common disease, which is very 
troublesome on account of the many symptoms to which it gives rise, 
produces very slight palpatory changes, and the diagnosis is not as a 
rule made by the general practitioner. Failing to find any gross lesions 
of the genitalia such as he is familiar with, he puts the patient down as 
nervous and hysterical and treats her accordingly. But a knowledge 
of the symptoms alone is often enough to indicate the diagnosis of this 
disease. The patient complains chiefly of pain coming on in positions 



500 GYNECOLOGICAL DIAGNOSIS 

and during occupations which cause displacement of the uterus on 
account of the traction on the diseased ligaments with which they are 
associated; for example, the pain is brought on bj' jumping, or bringing 
the feet down forcibly on the ground, lifting, reaching out, turning, 
during coitus and defecation. In these cases the patient should be 
carefulh' examined for disease of the above-mentioned ligaments by 
pushing tlie posterior vaginal vault upward and at the same time forcing 
the vaginal portion forward. The lateral portion of the parametrium 
and tliQ two infundibulopelvic ligaments must also be examined. In 
this way the cause of the symptoms is found very much more frequently 
than is generally believed in changes which are exceedingly slight and 
seem to have no direct connection with the symptoms. Sometimes 
it is impossible to make out any changes in the tissues, and one must 
be content with finding definitely localized pain on pressure. 

Differential Diagnosis. Mistakes are made more often in the 
direction of overlooking this commonest of all abdominal infections 
than in mistaking it for other conditions. Nevertheless mistaken diag- 
noses do occur. The pain produced in the diseased folds of Douglas 
by displacing the vaginal portion is sometimes erroneously referred to 
the vaginal portion itself, or to the vaginal vault, because the delicate 
changes in the ligaments are not detected by palpation. Pain produced 
in the infundibulopch'ic ligament may be erroneously referred to the 
ovar}', which the examiner holds between his fingers at the time the 
ligaments are stretched. Not infrequently one has to distinguish 
between parametritic and perimetritic adhesions. The latter may be 
situated anywhere in the neighborhood of the uterus, especialh' near 
the adnexa: wliile the former are always around the cervix and very 
close to the vaginal vault. The former are more numerous, while in 
posterior parametritis onl}' the two cords corresponding to Douglas' 
folds can be felt. Parametritic adhesions are ver}^ tense, tendinous, 
cicatricial, and cannot be torn, while perimetritic bands are delicate, 
often as fine as a spider's web, and tear at the slightest touch. Cervical 
parametritis causes fixation of the cervix, which is attached by con- 
nective tissue; while in perimetritis the body of the uterus is fixed at 
some point where it is covered with peritoneum. 



SPECIAL DIAGNOSIS 501 



Diagnosis of Uterine Catarrh. 

Definition. Catarrh, or inflammation of the mucous membrane, 
is a term appHed to a group of diseases characterized patliologically by 
hyperemia and the deposition of inflammator)' products in the form 
of exudates or young embryonal cells in or upon the mucous 

. . . • 1 1 Definition. 

membranes, and, m chronic conditions, accompanied b}^ 
multiplication and enlargement of the constituent elements of the 
mucous membrane. Clinically, catarrh manifests itself in an increased 
activity of the mucous membrane and its individual constituents, and 
in a number of symptoms which arise directly or reflexly from the 
altered mucous membrane or its inflammatoiy products. 

Classification. Catarrh may occur in any portion of the mucous 
membrane, from the vulva to the abdominal extremity of the tube. 
The various forms are classified as follows: 

Vulvitis, or catarrh of the mucous membrane of the vesti- 
bule and introitus vaginae. 
Colpitis or vaginitis, catarrh of the mucous membrane of 

the vagina, fiom the h3niien to the external os. 
Endometritis, or catarrh of the mucous membrane of the 
uterus, from the external os to the uterine orifices of the 
tube. This is further subdivided into: 

Cervical endometritis or catarrh, when the 
mucous membrane from the external os to the 
internal os is diseased, and 
Corporeal endometritis when it aft'ects the 
mucous membrane from the external os to the 
uterine orifices of the tubes. 
Endosalpingitis, or inflammation of the mucous mem- 
brane of the tube. 

Catarrh is rarely limited to one of these subdivisions of the genital 
tract and has a great tendency to spread from below upward, or, if it 
begins above, downward to the lower segments. For this reason 
catarrh of the mucous membrane must be regarded as a connected 
entity; but, owing to distinct structural and physiologic differences in 
the various portions of the mucous membrane, the pathologic and 
clinical pictures produced in them are quite different. For this reason 
we shall first describe the individual sections separately, and later discuss 
the disease as a whole from the common standpoint. While I shall 



502 GYNECOLOGICAL DIAGNOSIS 

begin with the upper portion of the tract, I shall for the present omit 
endosalpingitis, because it is the most important of the tubal diseases 
and has already been discussed in the chapter devoted to that subject. 

Endometritis. 

The term endometritis embraces a number of conditions with 
entirely different pathologic and clinical pictures, with such great 
differences in their etiology, pathology, and symptomatology that 
their lo^calization in the endometrium is their only connecting link. 
Hence, for didactic as well as for practical purposes, a subdivision 
of endometritis would be most desirable and, apart from the obvious 
classification into acute and chronic, circumscribed and diffuse forms, 
attempts have been made to base a classification on general principles. 
The most obvious and logical is the anatomic classification suggested 
by Huge, who subdivides endometritis into glandular, interstitial and 
diffuse, besides the minor forms — decidual, post-abortum, and exfoliat- 
ing endometritis. But for diagnostic purposes and for general practice 
this classification is useless, chiefly because it presupposes a micro- 
scopic examination, which cannot be made for diagnostic purposes, 
but must be delayed until treatment (in the form of operation or curet- 
tage) has been applied, and because the various pathologic pictures 
have no corresponding definite clinical conditions. Winckel proposes 
an etiologic classification of endometritis. There is no doubt this is 
the most correct from the scientific standpoint; but, aside from the 
fact that many of his twelve varieties are not as yet generally accepted, 
an etiologic division is for the present useless for diagnostic purposes 
because it is either impossible to recognize the cause, or its detection 
recpiires complicated methods of examination. For practical purposes 
a classification based on the three main symptoms, — hemorrhage, 
pain and discharge — into hemorrhagic, dysmenorrheic and catarrhal 
endometritis would be satisfactory, were it not that many cases present 
several symptoms in equal severity, and that a change from one symp- 
tom to another is often observed. In the present state of gynecologic 
diagnosis it seems to me better to abandon all attempt at classification 
and to view endometritis as a whole, except those forms which our 
present knowledge of diagnosis enables us to separate from the general 
picture of endometritis, such as gonorrheal, exfoliating, and fungous 
endometritis, which will be treated separately in the appropriate place. 

Diagnosis. 

In the diagnosis of endometritis we have to pursue a different 
method from that used in other diseases. Relying less upon the physi- 
cal signs, we base our diagnosis chiefly upon the symptoms. The reason 



SPECIAL DIAGNOSIS 503 

for this is that endometritis has no physical signs, the changes in the 
uterine cavity being quite insignificant; while, on the other hand, the 
symptoms are so characteristic and may produce such a clear clinical 
picture, that the diagnosis is often possible without examining the 
patient. I shall, therefore, reverse my usual method in the case of 
endometritis, and begin with the symptoms instead of the physical signs. 
It should be emphasized, however, that the patient's statements are 
not always reliable, particularly in the matter of hemorrhage and 
leucorrhea, which must be demonstrated objectively whenever possible. 
The most prominent symptom is hemorrhage, which usually 
takes the form of a menorrhagia, rarely occurring between the periods. 
The quantity of blood lost during the menses may be increased or dimin- 
ished ; since the quantity varies between wide limits in per- 

• • T rr 1 1 •• Hemorrhage. 

fectly healthy women, it is diincult to say what quantity is 
"too much. " If the patients state that the flow has become considerably 
more profuse than formerly, or that it takes a number of days, often from 
one to two weeks, to recover from the loss of blood, or that they "bleed 
very freely," that it "pours," "comes in a rush," or that they "float 
away," the hemorrhage may be regarded as pathologic. Blood clots are 
also a sign of very excessive hemorrhage. The duration of menstruation 
may be prolonged in endometritis. As here again we have no definite 
standard, and the period varies from two to eight days in healthy 
women, this symptom can be regarded as pathologic only if the period 
exceeds the above extreme, if the bleeding does not cease at all, or the 
period lasts considerably longer than had previously been the case. 
Menstruation rarely begins at the normal time; usually the intermen- 
strual periods are shortened, and the flow recurs every three weeks, or 
every two weeks, instead of four weeks — "twice a month." This may 
sometimes alternate with periods of amenorrhea lasting from two to 
three months, particularly after a severe hemorrhage. Intermenstrual 
hem-orrhage is, on the whole, more rare, but may occur after coitus, 
psychic emotion or bodily exertion. The patient usually states that 
the trouble has developed slowly, and increased gradually during a 
period of months or years; more rarely there is a history of severe 
menorrhagia occurring immediately after a normal menstruation. 

A less common, but no less important symptom of corporeal 
endometritis is leucorrhea. 

While the normal endometrium has no characteristic secretion, 
simple corporeal catarrh is accompanied by a seropurulent discharge. 
In acute conditions the discharge is seropurulent mixed with blood, 
and may consist entirely of pus; but in the chronic catarrhal forms 
the discharge is always more thin and purulent (seropurulent). Mucus 
is entirely absent in simple corporeal catarrh, and occurs only when the 



504 



GYNECOLOGICAL DIAGNOSIS 




UittSsis^' 



Fig. 302. — Schttltze 
(Dl.\GNOSTIc) T.\MroN. 



cervix is also diseased. The quantity of discharge is extremely variable; 
there are some forms of endometritis with violent symptoms in which 
there is verj^ little secretion, while in other cases the flow is quite profuse. 
The most abundant secretion is seen in the gonorrheal forms, particularly 
during pregnancy. The discharge is usually increased before and after 
menstruation; at times it may be altogether absent, or at least cease 
for a time. As a rule there is no odor; but sometimes, owing to the 
presence of the metabolic products of microorganisms, the discharge 
is very offensive. If the endometritis is associated with catarrh of the 
cervix and of the vagina, the corporeal secretion becomes mingled with 
the secretions of these two structures and loses its characteristic prop- 
erties. In cases of this kind it is particularly difficult to identif)^ the 
discharge as corporeal secretion. To begin with, it 
is not easy to determine whether a discharge which 
is found in the vagina has been secreted by the 
vaginal mucous membrane or has come clown from 
the uterus, particularly as the secretion of the 
body and that of the vagina may be quite similar. 
If the inspection with the speculum happens to 
be made at the instant when the secretion escapes 
from the external os, the question is decided at 
once; but in the majority of cases special methods 
must be resorted to in order to obtain this information. If it is 
to be decided whether the uterine secretion is a product of the body 
or of the cervix, it becomes imperative to separate it from the vaginal 
secretion, so as to be able to investigate its special properties. For this 
purpose Schultze's tampon (Fig. 302) is employed. It consists of loose 
cotton, sufficiently broad and not too thick, tied crosswise in both 
directions with a thread; it is better not to leave the thread long for 
the purpose of removing the tampon. The tampon is employed as 
follows: The vaginal parts having been exposed with a Simon speculum, 
the secretion adhering to the outer surface of the entire vagina is gently 
removed, taking care not to make the mucous membrane bleed because, 
if the secretion obtained for the purpose of examination is mixed with 
blood, the diagnosis is obscured. The tampon is then placed in front 
of the vaginal portion so that the os is exactly opposite the intersection 
of the threads, and pressed firudy into the vaginal vault, so that its 
position shall var}- as little as possible. If the secretion is very abun- 
dant, the tampon loosens prenuiturely; if the vagina is ver}^ wide and 
relaxed, it is apt to fall out. Under these circumstances it is better 
to place a second tampon in front of the first. After twentj^-four hours 
the tampon is removed by exposing the cervix as before in the Simon 
speculum, and seizing the lower extremity of the tampon with forceps. 



SPECIAL DIAGNOSIS 505 

Note. Schultze recommends that the tampon be saturated with a 20 to 25 per 
cent, solution of tannin in glycerin. After numerous experiments, I have satisfied myself 
that it is better to use a dry tampon for the following reasons: In the first place the abvmdant 
watery secretion induced by tlie glycerin is distmbing; and in the second place small (pianti- 
ties of mucus become so inspissated that they caniaot be recognized with certainty. Another 
reason is that the glycerotannin irritates the vagina and causes a desquamation of abundant 
squamous epithelium, wliich renders the secretion cloudy, and makes it difficult to decide 
how far the des(]uamation is due to the catarrh. Mucus and pus are difficult to distinguish, 
and it is not easy to determine whether the cervical secretion is glairy, or turbid from the 
presence of pus and epitlieliuin. 

In normal genitalia the spot in front of the external os where the 
tampon was placed will be covered with a small quantity of glairy 
mucus, and the cotton will bo stained light 3adlow, while the periphery 
of the tampon is covered with a glistening layer of desquamated vaginal 
epithelium. With the aid of the tampon it is easy to decide whether 
the secretion is derived from the uterus or the vagina. The former is 
always near the intersection of the threads, while the vaginal secretion 
is deposited only at the periphery. A more difficult question to decide 
is whether the cervix or the body is the source of the secretion. Up 
to a certain point this can be determined by the character of the material. 
Mucus is always derived from the cervix, whereas pure pus is secreted 
by the body. It is to be remembered, however, that erosions or pure 
cervical pus around an erosion may produce a slightly yellow purulent 
discoloration of that part of the cotton wliich was in contact with the 
erosion. The diagnosis is most difficult wlien the tanqjon coittains both 
mucus and pus. If the two nuiterials are intimately mixed, it is probable 
that they were both secreted at the same time by tlie cervix and tliat 
the case is one of purulent cervical catarrh; but if pure pus and pure 
mucus are present and not intimately mixed, it is a positive sign that 
both the body and the cervix are diseased; and if, in chronic cases, 
there is much more pus than would correspond to the quantity of mucus, 
a combination of corporeal and cervical catarrh is probable. If the 
vaginal portion presents erosions, ovula Nabothi or ectropion, cervical 
catarrh is probably present; although, on the other hand, the absence 
of these changes does not exclude it. The quantity of pus that is found 
on the tampon in corporeal catarrh varies considerably, indeed pus may 
be altogether absent in undoubted cases of the disease; hence corporeal 
catarrh must never be excluded on the strength of a single negative 
examination, and the latter must be repeated, preferably at times when 
the secretion is usually more abundant, as before and after menstruation, 
or at the time of the intermediate pain. It is unnecessary to examine the 
secretion for pus microscopically; but if there is any suspicion of uterine 
gonorrhea, it is a favorable material for the demonstration of gonococci. 

Another symptom of some value for the diagnosis is uterine 
pain. It has the character of labor pains and is tlescribed by 



506 GYNECOLOGICAL DIAGNOSIS 

the patient as a suddenly occurring, intermittent, cramp-lilce pain, or 
as a dull pressure associated with bearing down and pressure on the 
bladder. As a rule, the pain is directly referred to the region of the 
uterus; although some women refer the pain more to the 
umbilical region, and occasionally also underneath the arch 
of the ribs. These labor-like pains are undoubtedly due to uterine 
contractions, which are painful on account of the inflammation of the 
endometrium, and occasionally that of the entire uterine wall. The 
pains are characteristic of endometritis only when they are associated 
with the function of the uterine mucous membrane, i.e., with menstru- 
ation; while uterine cramps due to other causes frequentl}^ occur before 
and during the menstruation. (For the peculiarities of this endometritic 
dysmenorrhea, see the chapter on "Causes of Dysmenorrhea" in the 
part devoted to analytical diagnosis.) 

Much less frec^uently uterine pain in endometritis occurs in the 
form of intermediate pain, i.e., it occurs midway between two 
menstruations, and is often associated with the periodically appearing 
Intermediate leucorrhca. Sometimes uterine pain occurs quite irreg- 
^^^^- ularl}^ during the intermenstrual periods, and is in that 

case jDrobably due to retention of the secretions. Some women who 
do not complain of distinct pain mention all kinds of unpleasant sen- 
sations in the abdominal organs, such as persistent bearing down, a 
feeling of "swelling" and "thickness in the abdomen"; they "feel the 
womb"; they have an increased desire to defecate and urinate; they 
complain 'of pain in the abdomen, in the back and in both legs. These 
symptoms are considerably increased a few days before menstruation, 
or they occur only at that time, and are certainl}^ associated with 
the process of menstruation. As compared with monorrhagia and 
leucorrhea, uterine pain is a purely subjective symptom for the inter- 
pretation of which we must depend solely on the sensations and state- 
ments of the patient. It should therefore be utilized with great caution, 
and in those forms of endometritis in which pain is the only symptom 
every effort should be made to obtain some objective signs. 

Aside from these symptoms, which are quite definite and frequently 
constitute the only basis for the diagnosis of endometritis, there is 
another symptom-complex to be mentioned, which must be referred 
Premenstrual to the ucrvous systcui and the psychic condition of the 
Symptoms. patient. It is important for the diagnosis of endometritis 

because it is most intense during functional activity of the uterine 
mucous membrane, i.e., during menstruation. From four to six days 
before menstruation the patient begins to feel languid, miserable, 
"completely done out," complains of dragging pains in all the limbs 
as if she had been beaten; she becomes nervous, irritable, easily excited 



SPECIAL DIAGNOSIS 507 

and timorous-; sleep is restless and interrupted by dreams, and the 
patient's entire temperament and disposition change. Women who are 
otherwise quiet and peacable complain that during this time they are 
quarrelsome, vicious, and "not fit for an3''one to live with"; they also 
complain that they are unable to concentrate their thoughts. Some 
women become profoundly melancholic, lose all interest in life and 
even have thoughts of suicide. These psychic phenomena are sometimes 
observed in a milder form during the intermenstrual period also. The 
premenstrual symptoms, as they are called, represent an exagger- 
ated degree of what health)' women feel before and during their menstrual 
periods, and their explanation is found in the premenstrual engorge- 
ment of the diseased endometrium; or, in the case of infectious catarrh, 
in the increased absorption of toxins. It is very difficult to distinguish 
between what is normal and abnormal, particularly in psychic symp- 
toms. It should also be emphasized that these conditions are not 
exclusively s3'mptomatic of endometritis, and that they occur also in 
metritis and in diseases of the tubes and ovaries; they are, however, 
more pronounced in endometritis, especially the catarrhal form, and 
have a diagnostic value from the fact that they point to disease of the 
uterine mucous membrane. Gastric symptoms — nausea and vomit- 
ing — which are frequent concomitants of endometritis, are some- 
times the only symptoms complained of, to the entire exclusion of 
abdominal discomfort. When they are present, the endometrium 
should receive attention if no gastric cause can be found. 

The above-mentioned symptoms have a very great value for the 
diagnosis of endometritis, but they are not pathognomonic. With 
the exception of leucorrhea, definitely proved to be derived from the 
body, they are symptoms that occur also in other diseases, objective signs 
For this reason an attempt should always be made to obtain °^ Endometritis, 
some objective signs, and for this purpose the uterine cavity is 
examined with a sound. The finger is not so well adapted for discover- 
ing insignificant changes in the uterine mucous membrane as the small 
head of a sound in the hands of a skilful examiner. In a large number 
of cases the uterine cavity is greatly dilated, as shown by the 
large excursions and rotations in all directions that can be performed 
without difficulty with the sound. Dilatation of the cavity, it is true, is 
not found so frequently when the uterus contains abnormal matters, such 
as polyps or remains of abortions. In cases of subinvolution after oper- 
ation, or labor, or in chronic relaxation of the muscle the value of this 
sign is rather limited. Irregularities of the surface, which 
are found most frequently in the fundus and adjoining portions of the 
body, are much more important; but this sign also is not pathogno- 
monic, partly because irregularities are found also with carcinoma 



508 GYNECOLOGICAL DIAGNOSIS 

and the retention of decidual tissue, and partly because a normal endo- 
metrium may occasionall}^ show slight irregularities in its surface. 
On the other hand, the mucous membrane may be perfectly smooth 
in cases of extreme hyperplasia. Sometimes the examiner has a feeling 
as if the sound were sinking into the soft uterine mucous membrane, 
like the foot sinking into moss. Severe hemorrhage immediately after 
sounding also points to changes in the endometrium. The sense of 
roughness in the mucous membrane is most distinct in the fungous 
forms of endometritis, and is due to the ghding of the head of the sound 
over the prominences of the mucous membrane. A very important 
objective sign is marked tenderness of the endometrium during 
sounding. The tenderness is most frequently confined to the fundus 
or to the roughened areas and manifests itself as an intense, stabbing 
or spasmodic pain in the region of the uterus, around the umbilicus, 
or in the sacrum. The pain is sometimes so intense that the woman 
cries out, shrinks from the sound, or faints. The value of the symptom 
is impaired by the fact that nervous, timorous, and hyperesthetic women 
complain of pain even when the endometrium is healthy, and because 
perimetritic and parametritic pain, which is sometimes excited by 
sounding, is frequently mistaken for endometritic pain. To avoid this 
mistake the examiner should remember that the former is produced 
by the displacement of the uterus and the traction on adhesions incident 
to the introduction of the sound ; whereas endometritic pain is elicited 
only when the head of the sound comes in contact with the mucous 
membrane. Hence in doubtful cases the sound should be allowed to 
remain for a moment in the uterine cavity after its introduction, and 
then slowly and cautiously advanced until it touches the mucous mem- 
brane. The sound must not be employed for the diagnosis of all forms 
of endometritis. The method is most suitable for those associated with 
severe hemorrhage antl dysmenorrhea. In cases characterized by 
discharge, particularly purulent discharge, the sound should not be 
employed, and its use is strictly contraindicated in all cases with a 
suspicion of gonorrhea. As endometritis is frequently associated with 
perimetritis and parametritis, as well as with disease of the adnexa, 
the latter must be carefully examined before the sound is introduced. 
There are no distinctive bimanual signs in endometritis, with the 
exception possibly of a slight softening of the mucous membrane of the 
vaginal portion, particularly in the fungous forms, and quite frequently 
a slight thickening of the body, due to associated metritis. The object 
of combined examination in the diagnosis of endometritis is rather to 
exclude any other possible causes for the symptoms. These are chiefly 
carcinoma, myoma, disease of the adnexa, and inflammation. It may serve 
to confirm the diagnosis of endometritis by yielding a negative result. 



SPECIAL DIAGNOSIS 509 

The most reliable method of making a diagnosis of endometritis 
is b}' means of a microscopic examination of the uterine mucous 
membrane. As the symptoms on account of their ubiquity have so 
little diagnostic value, and the objective findings are negative in endo- 
metritis, it would be of great advantage if we could make the diagnosis 
more certain by resorting to this method; but the general emploj'ment 
of exploratory curettage, or even the removal of a few particles of 
mucous membrane for purposes of examination, is impracticable for 
the general practitioner because, aside from the very great discomfort 
to the patient, there is danger of injuring the uterine wall, or even caus- 
ing infection. Hence, except possibly in a few cases of special impor- 
tance, we are forced to advise against this method, unless there is a sus- 
picion of malignant disease. On the other hand, if the uterus has 
been curetted for therapeutic purposes, the mucous membrane should 
immediately be subjected to microscopic examination, the result of which 
will determine the subsequent treatment to be administered. Digital 
exploration of the uterus through an artificially dilated cervix is open 
to the same objections; it is much too painful to the patient, and not 
infrequently causes infection, hence its general employment for the 
diagnosis of endometritis is not to be recommended. Another disad- 
vantage is that the palpating finger is not always capable of recognizing 
irregularities in the surface, which can easily be felt with the sound; 
although occasionally the finger feels the reflected surface of the 
swollen and softened mucous membrane. Hence digital exploration 
should be performed only when some special cause for the endometritis 
is suspected in the uterus, such as a submucous myoma. 

Differential Diagnosis. 

As the palpatory findings in endometritis are entirely negative, they 
cannot give rise to diagnostic errors. The source of error which may 
arise with the sound, in th'e matter of pain especially, has already been 
discussed. Clinically the differential diagnosis in endometritis is based 
on the symptoms, because these also form the foundation of the diagnosis. 

In the main, therefore, it will have to be determined whether the 
hemorrhage may not be explicable by some other cause, such as 
carcinoma, myoma, or tubal inflammation. If all these diseases, which 
are characterized by definite physical signs, can be excluded — in other 
words, if the objective examination yields the negative result which is 
characteristic of endometritis — it will have to be determined further 
whether the hemorrhage may not be a purely symptomatic phenomenon 
due to some internal trouble, or a circulatory disturbance of a local 
or general nature. The etiologic diagnosis of uterine hemorrhage is 
so difficult and so important that I have discussed it in a special chapter 



MB 



510 GYNECOLOGICAL DIAGNOSIS 

under Analytical Diagnosis, and as I have there shown under what 
conditions endometritis may be held responsible for the hemorrhage, 
I shall not discuss the point in detail in this place. 

The same course is pursued with regard to the other symptom of 
endometritis — the uterine pain. Again we must exclude by careful 
bimanual examination all the causes of dysmenorrhea which are char- 
acterized by definite physical signs, such as myoma, disease of the ova- 
ries and of the tubes; and if the result of the objective examination is 
negatiye, we shall have to inquire whether the dysmenorrhea is clue 
to endometritis or to some other local or general disturbance. This 
important question is also discussed in the part devoted to Analytical 
Diagnosis, and I shall therefore not dwell on it in this place. 

In those cases in which the diagnosis of endometritis has to be 
made chiefly by the increase in the uterine discharge, the tampon 
must be used in order to demonstrate that the discharge is derived 
from the uterus (see page 505). From hypersecretion, due to tem- 
porary functional disturbance, endometritis may be distinguished by 
the duration of the symptoms, and its association with local and general 
subjective symptoms (see above). 

For the microscopic differential diagnosis of 
endometritis see page 540. 

Diagnosis of the Various Forms of Endometritis. 

I have already given my reasons for treating endometritis as a 
whole from the diagnostic standpoint instead of subdividing it into its 
various forms. Nevertheless a _ number of varieties can be separated 
from the general picture of endometritis, with definite etiologic, as well 
as pathologic and clinical characteristics, so that it is possible to describe 
them as separate diseased conditions of the endometrium. As it is 
important for the physician to know these forms, and to be able to 
identify them in a given case, I shall trj^ so far as possible to define 
these individual varieties and to give their diagnostic features. 

Acute septic (non-puerperal) endometritis is an infectious inflam- 
mation of the endometrium, due to the entrance into the uterine 
mucous membrane of microorganisms (streptococci, staphylococci, 
bacterium coli, and saprophytes). The diagnosis is based 

Acute Septic . ' I r J ^ o 

Non-Puerperal cliiefly ou the profuse discharge from the body, which 

Endometritis. , . ^ i i • 

may be serous, bloody, purulent, dn'ty from the admixture 
of tissue particles, and ofl^ensive or putrescent; and secondarily on 
general constitutional disturbances, more particularly fever. There are 
no characteristic physical signs, except moderate tenderness of the uterus 
and slight softening of the vaginal portion and vagina. 

Catarrhal endometritis is a chronic inflammation, the cause of which 



SPECIAL DIAGNOSIS 511 

must also be an infection of the uterine cavity with microorganisms, 
probably the above-mentioned microorganisms of wound infection. 
It is frequently secondary to the above form. The pathologic changes 
consist merely in hyperemia and infiltration of the mucous catarrhal 

membrane. The diagnosis is based chiefly on the presence Endometritis. 
of a seropurulent secretion from the body, and in many cases on well- 
marked premenstrual sj'mptoms, while menorrhagia and dysmenor- 
rhea are more rare. Palpation and sounding yield negative results; 
roughness and endometrial tenderness are almost regularly absent. 
In these forms the use of the tampon is indispensable. 

Gonorrheal endometritis, due to infection with gonococci, is an 
inflammation accompanied by profuse purulent discharge, which usually 
begins acutely and runs a chronic course. The pathology is approxi- 
mately the same as that of catarrhal endometritis. The Gonorrheal 
clinical diagnosis is based on the finding of a purulent Endometritis. 
secretion from the body containing gonococci, or at least on the positive 
clinical demonstration of gonococci in every portion of the genitalia 
(see page 523). Hemorrhage may occur during the acute stage, and 
may be absent after the disease has become chronic. Premenstrual 
symptoms are almost never observed. There are no objective signs; 
sounding is contraindicated. On the other hand, if there is tubal 
disease, gonorrheal endometritis may be suspected. 

Tuberculous endometritis is caused by infection of the uterine 
mucous membrane with tubercle bacilli. A positive diagnosis demands 
the demonstration of tubercles and tubercle bacilli in scrapings of the 
mucous membrane. The disease may be suspected in the Tuberculous. 
presence of endometritic symptoms occurring in a tuber- Endometritis. 
culous woman, particularly if the existence of tuberculous peritonitis- 
and salpingitis, or of tuberculous ulcers in the vaginal portion, can 
be demonstrated. The symptoms are not characteristic, with the 
exception possibly of a cheesy, granular discharge. In advanced cases- 
amenorrhea is frequently observed. 

Fungous endometritis is characterized pathologically by extreme 
hypertrophy of the mucous membrane of chronic, interstitial, glandular, 
or diffuse character; clinically it is distinguished from other forms 
by the severity and frequent recurrence of menorrhagia. Fungous, 

the comparative rarity of dysmenorrhea, and the regular Endometritis, 
absence of leucorrhea. The diagnosis is based on menorrhagia 
associated with the demonstration of irregularities at the fundus, 
dilatation of the uterine cavity and, occasionally, bogginess or softening 
of the mucous membrane of the vaginal portion. Endometrial tender- 
ness is usually absent; no information is to be obtained with the tampon. 
Exploratory curettage is permissible only if there is a suspicion of 



512 GYNECOLOGICAL DL4GNOSIS 

malignancy. A positive diagnosis frequently requires a microscopic 
examination of portions of the mucous membrane removed during a 
therapeutic curettage. The adnexa are usually free from disease. 

Dysmenorrheic endometritis is characterized clinically by pain 
which is chiefly, or even exclusively uterine in character — particularly 
dysmenorrheic and intermediate pain — and b}^ the absence of hemor- 
Dysmenorrheic rliagc and cUscliarge. The pathologic process is usually a 
Endometritis. chrouic interstitial exudation, but glandular forms are 
also ojDserved. The diagnosis is based on the existence of a uterine 
dysmenorrhea, extreme tenderness on pressure in the endometrium, 
irregularities in the mucous membrane, and occasionally contraction 
of the uterine cavity. The tampon gives no information and the 
palpatory findings are negative. 

Exfoliating endometritis (dysmenorrhoea membranacea) 
represents a chronic inflammation of the uterine mucous membrane, 
characterized clinically as a rule by severe dysmenorrhea and always 
Exfoliating by the discharge of the uterine mucosa, in small pieces or 

Endometritis. coliereut membrancs, between the second and fifth day of 
menstruation. 

The diagnosis is based on the expulsion of an organized 
membrane during menstruation. In the differential diagnosis 
we must exclude membranous clots and croupous membranes, which 
are distinguished by their friability and the fact that they disintegrate 
spontaneously, especially when placed in water. If the expelled mem- 
brane is definitely identified as a piece of organized mucous membrane, 
it may be menstrual decidua, or the decidua of uterine or extra-uterine 
pregnancy. The distinction may be very difficult. If menstruation 
occurs at the regular time, and the membranes are expelled repeatedly 
at these times, the case is one of endometritis; but if a membrane is 
expelled only once, or only at very long intervals after menstruation 
has been delayed, even if onl}'' for a few days, the condition is more 
probably abortion or extra-uterine pregnancy. In many cases micro- 
scopic examination is necessary to establish the diagnosis (see page 529). 

Note. Exfoliating endometritis in its symptoms and pathology closely resembles 
dysmenorrheic endometritis, of which it forms a subvariety. I have seen dysmenorrheic 
endometritis, after a considerable duration, converted into exfoliating endometritis. 

Decidual endometritis is an inflammator)^ disease of the uterine 
mucous membrane which occurs during pregnancy. The diagnosis of 
Decidual this foriTi of endometritis is particularly difficult, because 

Endometritis. examination of the uterine cavity is impossible at this 
time, and sole dependence must therefore be placed on the symp- 
tomatology. The symptoms also consist of hemorrhage, discharge, 



SPECIAL DIAGNOSIS 513 

and uterine pain. The hemorrhage often occurs before it is 
possible to recognize the amenorrhea of pregnancy, and may persist 
often for several months; the severity is variable; the blood at times 
recent and venous; at others of a brownish color and mixed with 
mucus as the result of retention. Sometimes the discharge consists 
merely of a pinkish mucus. The secretion of the corporeal cavity 
is usually purulent and, in the case of gonorrheal forms, very 
abundant; occasionally a profuse watery flow is observed (hydror- 
rhea uteri gravidi). The tampon must be employed in order 
to determine the uterine nature of the discharge. Persistent pain 
of a distinctly uterine character may be present, or the labor pains 
of pregnancy. The latter are decidedly the most important 
symptoms of decidual endometritis, and for many months may consti- 
tute the patient's chief complaint. All the symptoms, particularly 
hemorrhage and discharge, are most prominent during the first half of 
pregnancy and disappear after the decidua vera and reflexa have united. 
The diagnosis of decidual endometritis is rendered more probable if 
endometritis is positively known to have been present before the begin- 
ning of pregnancy, or appears at least very probable from the patient's 
statements. Clinically, it is impossible in those cases in which no symp- 
toms whatever are complained of during pregnancy, or before pregnancy 
began. Cases of this kind are not very rare, and abortion is then the only 
expression of the disease; but the diagnosis is probable only if repeated 
abortions occur, particularly during the early months. Examination of 
the expelled fetal membranes is the only certain method of arriving at the 
diagnosis, and they must therefore always be subjected to both macro- 
scopic and microscopic examination if there is a suspicion of this disease. 

Cervical Catarrh. 

Definition. Cervical catarrh, or endometritis cervicis, is an 
inflammation of the cervical mucous membrane from the external os 
to the internal os, in the course of which inflammatory manifestations 
may also appear on the outer surface of the vaginal portion. 

Diagnosis. The diagnosis of cervical catarrh is easier than 
that of endometritis, because part at least of the diseased mucous 
membrane can frequently be seen, and because the changes in the outer 
surface of the vaginal portion, which are easily recognized, 
occur only as the result of cervical catarrh. When the 
cervix is brought down into a Simon speculum, and the two lips everted 
with a tenaculum for the purpose of obtaining a better view, the mucous 
membrane appears bright red in color, soft and velvety. The outer 
surface of the vaginal portion, where the changes to be mentioned 
develop, is then inspected, as these changes are a positive sign of 

33 



514 GYNECOLOGICAL DIAGNOSIS 

an existing cervical catarrh. They consist of erosions, ovula 
Nabothi, mucous polyps, and ectropion with metritis colli. 
Erosions are changes of the mucous membrane that cover the 
vaginal portion, consisting in exposure of the cylindrical epithelium 
after separation of the thick squamous epithelium which normally 
covers the structure. The diagnosis is very easy. The 

Erosions. .... ,, . 

external os, which is usually somewhat dilated, is sur- 
rounded b}' a glistening surface of variable extent and continuous 
with the cervical canal, instead of by the normal, pale-violet squamous 
cpithelii\m; the color ranges from a delicate pink in general anemia, 
to an intense scarlet in the presence of recent catarrh, or even purple 
if the condition is complicated by pregnancy. The surface is slightly 
roughened or furrowed; not sharply outlined at the peripher}', but 
merging in an irregular manner with the surrounding squamous epithe- 
lium. In reparative processes islands of epithelium are occasionally 
seen at the centre of the erosion, or the entire area may be com- 
pletelj' covered with a delicate squamous epithelium; but a healed 
erosion is much more purple in color than the more robust normal 
epithelium. The surface is coveretl with a mucoid secretion; erosions 
are often covered with a yellowish exudate and exhibit superficial 
ulcerations when the epithelium is lost. Thej^ l)leed easily, sometimes 
spontaneousl)^, and always when the surface is wiped off. 

We distinguish simple erosion, with uniform, fairly smooth 
surface and without deep depressions; papillary erosion, in which 
the surface is irregularl}^ nodular or marked by ridges with deep, regular 
depressions of glandular tissue into the vaginal portion; and follic- 
ular erosion, the entire surface of which, especially the peripheral 
portion, presents follicles in the form of yellow points or small cysts 
the size of lentils, which, when opened, discharge inspissated mucus or 
form small, roundish dimples, representing the remains of ruptured cysts. 

Ovula Nabothi are small retention cj^sts which develop from 
the fundus of the glands of the cervical mucous membrane or of the 
erosion after constriction of the tluct. At first situated more deeply, 
Ovula theji' become distended and reach the surface, being found 

Nabothi. most frequently around the healing erosion; they are 

frequent!)' felt as small, circumscribed nodules which, when conglomer- 
ated, project above the level of the vaginal portion. To the eye they 
appear as circumscribed, small prominences, and the pale or yellowish 
contents are visible through the mucous membrane. If these retention 
cj^sts remain in the depths of the tissue the}' produce a circumscribed 
or general thickening of the vaginal portion; if the interglandular 
tissue also becomes hypertrophied, the condition is known as a 
follicular hypertrophy. 



SPECIAL DIAGNOSIS 515 

In connection with chronic cervical catarrh there are found 
mucous polyps consisting of circumscribed hyperplasias of the cer- 
vical mucous membrane. If they are situated in the lower Mucous 
portion of the cervix, or project from the external os, Polyps, 
they are both palpable and visible. The size varies from that of a pea 
to that of an egg, and the pedicle also varies in length. The surface is 
rarely smooth, usually lobulated, with a suggestion of division into 
several portions; lacunae and large or small retention cysts are present. 
The consistency is soft; the mucous membrane glistening, of a bright 
red color, bleeding easily, and covered with mucus. Old polypi pro- 
jecting into the vagina may be covered with squamous epithelium, but 
always retain a purplish color like that of a healing erosion. 

The sequels of cervical catarrh in the form of chronic indurated 
processes in the cervical substance, known as metritis colli, are 
easily recognized by palpation. The entire surface becomes firm and 
hard, fibrous and unyielding, and the vaginal portion thick Metritis Coin 
and shapeless. If there are bilateral cervical tears, the ^nd Ectropion, 
hypertrophied submucous tissue protrudes from the cervical canal 
and produces an ectropion, which is easily recognized by the broad, 
thick, shapeless vaginal portion, and the turned-over, mushroom-shaped 
lips, the anterior lip being often elongated like a snout. In the speculum 
the bilateral lacerations and the exposed cervical mucous membrane 
with its catarrhal changes, and the epidermidalization beginning at the 
margin, are seen. In bilateral lacerations the external os is felt and 
seen on one side elongated as far as the vaginal vault. The two edges 
of the lacerations are thickened and the seat of ectropion, and the 
cervical mucous membrane is exposed on one side only. 

Cervical catarrh in nulliparous women with contracted external 
OS produces a peculiar picture. The small external os appears as a black 
point, because the cervix is filled with mucus and does not reflect the 
light. The mucus is retained, becomes inspissated, and dilates the cervi- 
cal canal. The ampullary dilatation is easily recognized with the sound, 
and the inspissated mucus can be evacuated by pressing on the cervix. 

In all cases of cervical catarrh, and particularly in those in which 
the changes just described are absent, examination of the secre- 
tion plays an important role; unless the secretion is found to be 
abnormal, a diagnosis of cervical catarrh is not admissible. Examination of 
The cervical secretion is obtained by bringing the cervix the secretion, 
into the speculum and waiting until it flows from the external os, or by 
compressing the cervix with the two blades of a Simon speculum. If 
the secretion is scanty, it is better to insert a tampon; after twenty- 
four hours it will contain a quantity of secretion sufficient for diagnosis, 
and after its removal a larger quantit}^ will be seen to flow out of the 



516 GYNECOLOGICAL DL4GNOSIS 

cervix. Normal cervical secretion is a glairy, viscid mucus. In catarrh 
various changes take place. In the first place, the cjuantity is altered, 
it may be increased and accumulate in the vagina, or stain the external 
genitalia and clothing; on the other hand, the secretion may become 
inspissated, so that there is no discharge whatever, or only a few par- 
ticles are obtained. From the diagnostic standpoint the quantity of 
mucus contained in the secretion is most important. The cervix is the 
only portion of the genitalia that secretes genuine mucus, hence if an 
abnornial quantity of mucus is found, the cervix must be exclusively 
or chiefly diseased. The cervical secretion is viscid and forms threads 
from the edge of the external os to the speculum, or may be wiped 
off in long threads with cotton; it may be clear and watery, with- 
out any turbidity whatever, but is usually somewhat grayish from 
the presence of epithelial cells and leukocytes. Pus is the most 
frequent admixture, particularly in cases of infectious catarrh; the 
color of the mucus is changed, and may vary from a slightly yellowish 
tinge to a dark, yellowish-green color. Sometimes the quantity of pus 
is so abundant that the mucus, and with it the viscosity of the secretion, 
practically disappears. Occasionally a little blood is found in the 
secretion. In the catarrh of nulliparous women with contracted external 
OS it is difficult to make a diagnosis by the secretion. 

Differential Diagnosis. An abundant secretion from the cer- 
vical canal may be a symptom of inflammation or genuine 
change of the mucous membrane, or the production of a functional 
Differential disturbauce — a hypersecretion. The above-mentioned 

Diagnosis. inflammatory changes of the cervical mucous membrane, 

especially erosions and ovula Nabothi, always point to catarrh, as does 
also the admixture of pus; but if the secretion consists solely of 
clear mucus, the diagnosis is more difficult. Pure hypersecretion is 
observed, for example, in pregnancy with tumors of the cervix, with 
inflammations in the neighborhood of the cervix, in congestive 
conditions of the abdomen, and very often in chlorosis. 

An erosion may be mistaken for a number of other affections 
of the vaginal portion. In cases of ectropion the everted cervical 
mucous membrane is often mistaken for an erosion, because in the 
speculum the external os, which forms the boundary between the 
cervical canal and the outer surface of the vaginal canal, is overlooked. 
The diagnosis between these two conditions depends on the position of 
the os; whatever is outside of the os is erosion, and whatever is behind 
it is cervical mucous membrane. To determine the position of the 
external os, the two lips of the cervix are seized at their outer surface 
with a double tenaculum, and then brought together again, restoring 
the shape of the vaginal portion; as this is done, the cervical mucous 



SPECIAL DIAGNOSIS 517 

membrane disappears from view in the interior of the uterus. In simple 
erosions the external os is usually much smaller, and the vaginal portion 
is not mushroom-shaped. The circumscribed redness which develops 
on the outer surface of the vaginal portion in cases of colpitis, bears 
a certain resemblance to an erosion; but it is usually arranged con- 
centrically around the os, the surface is less velvety than that of an 
erosion, the condition representing merely a redness of part of the 
mucous membrane, with thinning of the epithelium. These areas bleed 
very easily, and a small quantity of pus is also found on the tampon. 
For the differential diagnosis between erosions and carcinomatous, 
tuberculous and syphilitic ulcers, see page 352 et seq. 

Colpitis. 

Definition. Colpitis is a catarrhal inflammation of the mucous 
membrane of the vagina from the hymen to the external os. 

The diagnosis of colpitis is based on the changes in the mucous 
membrane and the character of the vaginal secretion. It is quite easy 
except in those cases in which the speculum cannot be introduced, as 
in children, when the hymen is intact, or if there is vag- 

' J ' o Changes in 

inismus. In the acute form the mucous membrane is the Mucous 

diffusely reddened, the color varying from pale red 
to flaming scarlet, and sometimes slightly purplish; the discoloration 
is uniformly distributed over the entire vagina, except in colpitis second- 
ary to infectious cervical catarrh, in which the discoloration may be 
confined to the posterior vaginal wall in contact with the external os. 
The diffuse redness is usually associated with a linear and patchy h5^per- 
emia, produced by excessive injection of the papillary body. Very 
pronounced reel patches are seen, especially in the upper portions 
of the vagina — the structures look as if they had been spattered with 
red ink — or red lines, or stripes corresponding to the elevation 
of the folds. In mild and chronic forms these reel patches are the only 
manifestations of the changes in the mucous membrane. When the 
vaginal walls are separated with the speculum, a small drop of blood 
may escape from the red patches, or the surface may bleed when it is 
wiped off, or ecchymoses may be seen. These patches and ecchy- 
moses are seen most distinctly in old women in whom the squamous 
epithelium is attenuateel. The circumscribed hyperemia often leaels to 
hemorrhages during examination; when the inflammation is more 
intense, the papillary body swells and the folds as well as the papillae 
project at the level of the mucous membrane; these changes are more 
conspicuous in pregnant women. The inflammatory swelling, in asso- 
ciation with the hypertrophy of pregnancy, produces thick granular 
proliferations on the mucous membrane (colpitis granular is). 



518 GYNECOLOGICAL DIAGNOSIS 

Occasional!}^ chronic hypertrophy develops in the inflamed papillse and 
condylomata acuminata are produced, forming small, wart-hke 
prominences, with a rough white surface, which usualty occur singly 
in the vagina or on the outer surface of the vaginal portion. In one case 
I saw minute warts springing from each papilla. The outer surface of 
the vaginal portion is also covered with red patches which bleed easily 
and throw off their epithelium (erosion of the vaginal type). In preg- 
nant women, rarely in the non-pregnant state, vesicles containing gas 
develop in the mucous membrane under the action of gas-forming 
microorganisms (colpitis emphysematosa). These are found 
singly or in groups, usually on the posterior wall; in the speculum 
they are readily distinguished from swollen papillae by the thin and 
desquamated epithelial covering; when they are punctured under 
water, gas is liberated. 

In the rare cases of diphtheritic colpitis the vaginal wall, 
either in places or in its entirety, is discolored a dark gray or green, 
alternating with purplish portions, and later comes away in shreds. 

The palpatory signs are of secondary importance to those 
obtained by inspection. In diffuse acute catarrh the mucous membrane 
feels uniformly soft and velvety, and is quite sensitive if the condition 
is acute. Swelling of the papillae, especially in pregnancy, and the 
vesicles of emphysematous colpitis are also felt without difficulty. 
In senile colpitis cicatricial bands, the result of adhesions of the two 
vaginal vaults, or obliteration of the vaginal vault produce pecuhar 
palpatory signs. On moderate pressure with the finger the adhesions 
tear with the production of a slight hemorrhage. 

Examination of the secretion is important for the diag- 
nosis. Whereas normally the vagina merely desquamates small quantities 
of epithelial cells, qualitative and quantitative changes in the secretion 
Examination ^rc fouud lu cvcry form of vaginal catarrh. The squamous 
of the Secretion, epithelium may be desquamated in excess, forming 
small masses and, in the absence of fluid, appearing in the form of thick, 
white particles on the surface of the cervical mucous membrane. When 
these are removed, the mucous membrane underneath appears intensely 
reddened. In other cases serum is secreted from the vascular loops 
in the papillae and, mingling with the desquamated epithelial cells, 
becomes whitish and more or less viscous. If cervical mucus is 
present, the epithelial cells appear as white particles; the serous fluid 
is derived from the vagina, while mucus is always of cervical origin. 
A milky, serous secretion is characteristic of the vagina. 
In acute, and especially in infectious forms, pus is superadded, and 
the secretion assumes a slightly yellowish color. The more acute the 
process, the yellower and more purulent the secretion. Pure pus in 



SPECIAL DIAGNOSIS 519 

very large quantities is secreted in gonorrheal granular colpitis during 
pregnancy; if gas-forming microorganisms are present, the secretion 
becomes spongy. Purulent secretion is not characteristic of the vagina 
alone, as it may also be derived from the uterus. In most cases 
inspection of the mucous membrane suffices to determine whether 
part of the secretion comes from the vagina, but in doubtful cases 
the uterine cavity must be shut off with a tampon. In colpitis the 
tampon will be found more or less saturated with fluid, and the 
surface presenting toward the vagina covered with pus. In macular 
colpitis the tampon is covered with yellowish dots, each corresponding 
to a patch on the vagina. 

Differential Diagnosis. The differential diagnosis between colpi- 
tis and simple hypersecretion may be difficult. The latter 
is found in pregnancy, with inflammations, exudates, 

.,•111 1 /• 1 • • Differentia 

and tumors in the neighborhood of the vagina, in chlorosis Diagnosis from 
and other forms of anemia, after excessive irritation by 
coitus, and masturbation. The presence of pus, or severe hyperemia 
of the mucous membrane, always renders inflammatory changes of the 
mucous membrane more probable. 

Thrush of the vaginal mucous membrane produces a 
picture similar to that of colpitis with desquamation of epithelium. 
The disease occurs most frequently in pregnancy and also leads to the 
production of whitish patches on the mucosa. The patches, however, 
are not very extensive and usually occupy the top of the folds; they are 
not so readily wiped off, and stick fast in the uppermost layers of 
epithelium, hence their forcible removal is followed by hemorrhage. 
Examination of the white patches in diluted caustic potash shows large 
quantities of epithelial cells only in the case of colpitis, and the mycelium 
of oidium albicans if thrush is present. 

In rare cases part of the mucous membrane sloughs off in colpitis 
and is discharged in large coherent shreds. This frequently occurs after 
cauterization with iodin. It is practically impossible to mistake such 
membranes for uterine products because they represent merely a layer of 
squamous epithelial cells and not a complete mucous membrane; under the 
microscope, the large cells with their central nuclei are easily recognized. 

Vulvitis. 

Catarrhal vulvitis is an inflammatory disease of the mucous mem- 
brane of the inner surface of the labia majora, the labia minora, clitoris, 
and vestibule, as far as the hymen. It is frequently catarrhal 

combined with inflammations of the mucous canals that Vulvitis. 

open into the vestibule, i.e., the urethra, the ducts of Bartholin's glands, 
and Skene's ducts. The diagnosis is based almost exclusively on the 



520 GYNECOLOGICAL DIAGNOSIS 

changes in the mucous membrane, which are easily recognized by 
inspection. In recent, and particularly in infectious cases, the mucous 
membrane is diffusely reddened, pale, or bright scarlet in color, especially 
at the introitus; in chronic cases it is paler, but marked with reel 
patches and stripes at the border of the hymen, immediately around 
the urethral orifice, on the outer surface of the hymen, and at the 
excretory duct of Bartholin's glands. The mucous membrane bleeds 
when roughly handled (as during the introduction of a speculum), 
especially at the above-mentioned hyperemic places; touching the 
inflamed parts too frecjuently elicits contractions of the constrictor 
cunni and the muscles of the pelvic floor. In acute cases the greater 
and lesser labia are swollen. 

The discharge in acute cases is purulent and mixed with the 
viscid, tenacious mucus of Bartholin's glands. In vulvitis macu- 
losa there is no secretion whatever, and the mucous membrane is 
covered with shreds consisting of desquamated squamous epithelium; 
on the other hand, milky or purulent secretion can sometimes be 
expressed from the smaU recesses in the membrane. 

Vulvitis pruriginosa or pruritus vulvae is a chronic inflammation 
of the vulvar mucous membrane, with intense itching as the most 
prominent symptom. In recent cases the mucous membrane shows 
no alteration, but in protracted conditions the mucous membrane, as 
well as the surrounding skin, as a result of the scratching and rubbing, 
appears relaxed, withered, and puckered, especially around the pre- 
puce and clitoris, and the color is a bluish-gray; here and there scratch 
marks are seen. The pruritus is secondary, clue to the constant irrita- 
tion of abnormal secretions which accompany various conditions, such 
as endometritis, carcinoma, menstruation; or of urine containing 
abnormal constituents, as in diabetes mellitus, nephritis, icterus; or 
the irritation of parasites; in rare cases the cause is a venous hyperemia 
accompanying tumors or a cardiac lesion. Hence the most important 
part of the diagnosis consists in discovering the cause of the itching, 
because its removal is also the most important therapeutic indication. 
The most frequent causes are endometritic secretions and diabetes. 
The urine should always be examined for sugar in well marked cases of 
vulvitis. It is quite common for diabetes to be discovered first in the 
gynecologist's office. 

Craurosis vulvae is an atrophic condition affecting the corium of 
the mucous membrane covering the labia majora and minora and the 
Craurosis lutroltus. Thc greater labia appear flat, while the labia 

Vulvae. minora may be entirely wanting, or merely suggested by 

two flat longitudinal ridges; the clitoris is small and usually completely 
hidden underneath the folds of the atrophic mucous membrane; the 



SPECIAL DIAGNOSIS 521 

introitus is contracted; the mucous membrane is whitish, with gray 
spots, and atrophic. The difference between craurosis vulvae and 
pruritus vulva? consists in the contraction of the introitus and the 
atrophic condition of the skin in the former, as compared with the 
relaxation observed in the latter. 

Diagnosis of the Extension of the Catarrh. 

Catarrhal disease of each segment is definitely limited by its own 
physical signs and symptoms. Frequently, however, the physical 
signs, either the secretions or the changes in the mucous membrane, 
are mixed because several segments are attacked at the same time, or 
because the catarrh spreads secondarily to neighboring organs; hence 
it becomes the physician's duty to determine the extent and extension 
of the catarrh in the genitalia. From the standpoint of treatment 
it is particularly important to ascertain whether the uterus as well as 
the vagina, or the body as well as the cervix, is diseased; the treatment 
must, if possible, include the highest portions affected; otherwise they 
will constantly reinfect the lower segments after the catarrhal process 
has been arrested in the latter. For practical purposes it is always 
best to examine from below upward. If a patient consults her physician 
for leucorrhea, the first point to ascertain is the quantity of the dis- 
charge, as shown by the appearance of the clothing and the external 
genitalia. At the same time the effects of the irritating secretions are 
noted in the vulva and on the inner aspect of the thighs in the form of 
redness, eczema, and cutaneous ulcers. Next, the vulva is inspected 
and if the findings are positive, and particularly if the inflammation is 
acute, the urethra, the glands of Bartholin and the small mucous canals 
are included in the examination. In cases of gonorrheal catarrh the 
presence or absence of infection of the rectum must be determined by 
inquiring about the discharge of pus and rectal symptoms, as well as 
by inspection with a rectal speculum. The next step is the introduc- 
tion of the speculum for the purpose of examining the vagina, the outer 
surface of the vaginal portion, and the cervical mucous membrane as 
far as it can be seen. It is extremely important to determine whether 
the catarrh is limited to the vagina or involves the uterus also. If on 
repeated examination the vagina is found to contain only a white, 
milky, serous, or granular secretion, disease of the uterus may be ex- 
cluded; if mucus is found in the vagina, it is a positive sign of cervical 
involvement. If, on the other hand, the secretion in the vagina is puru- 
lent, either pure pus or seropurulent, it may be derived from the vagina, 
or may have escaped from the uterine body. The first point is easily 
determined by inspecting the vaginal mucous membrane, and by noting 
whether abnormal secretion escapes from the external os it can be deter- 



522 GYNECOLOGICAL DIAGNOSIS 

mined whether some of the discharge is produced in the uterus. A still 
better method of deciding the question, however, is the application of 
the Schultze tampon, which must always be employed if the vagina is 
found to contain pus. As a rule it is quite easy by this means to decide 
whether the uterus is diseased in addition to the vagina; on the other 
hand, it is much more difficult to make out whether the uterine body 
alone, or both together, are concerned in the catarrhal processes. In 
typical cases it is eas}^ to recognize whether the secretion on the tampon 
is purulent or seropurulent (corporeal catarrh), or simply mucous 
(cervical catarrh) ; but in most cases the secretion is a mixture of pus 
and mucus, and its origin is difficult to determine (see page 505). Hence 
the tampon sometimes fails to yield the important information whether 
the catarrh has involved the uterine body or has not extended beyond 
the internal os. In doubtful cases of this kind the following symptoms 
are in favor of corporeal disease: Severe dysmenorrhea or intense 
menstrual pain, as described above, point to endometritis. Severe 
menorrhagia in cases of recent, and particularly purulent cervical 
catarrh, cannot always be regarded as a sign that the catarrh has extended 
to the body, as it may be merely the expression of a concomitant hyper- 
emia of the uterus. In the latter case it ceases with the acute stage. 
If, however, the menorrhagia persists for some time into the chronic 
stage, there is strong reason to suspect that the body also is involved. 
If tubal disease is found associated with cervical catarrh, it is a positive 
sign that the infection has passed through the body, but not necessarily 
that it has produced a permanent change in the mucous membrane. 
Sounding cannot be employed for the diagnosis of corporeal disease 
in most cases, because it is too dangerous. 

Diagnosis of Gonorrhea. 

After the seat and extent of the catarrh in the genital organs and 
adjoining regions have been determined, the next question to decide 
is whether the process is gonorrheal. Although certain other causes 
are not without importance, particularly as regards prophylaxis and 
treatment, the demonstration of gonorrhea is by far the most important 
point on account of the frequency of the disease, the danger of its 
spreading upward, the fact that it is contagious, and the radical 
differences in the treatment of this infectious disease. 

The diagnosis of gonorrhea may be made by demonstrating the 
presence of gonococci and the specific changes which they produce in 
the affected membranes. 

The presence of gonococci is positive proof that the infection 
is gonorrheal and is not approached in importance by any clinical sign; 
but the biologic pecuharities of the gonococcus, and the peculiar condi- 



SPECIAL DIAGNOSIS 523 

tions existing in the mucous membrane of the female genital organs, 
greatly impair the value of bacterioscopic diagnosis. In the first place, 
the gonococcus can be satisfactorily demonstrated only in those por- 
tions of the mucous membrane in which it is present alone, or associated 
with a few other microorganisms. It is found most easily in the ure- 
thral secretion, in the vulvovaginitis of children, and in the cervical 
secretion of nulliparous women; while it is much more difficult to 
demonstrate in the cervical secretion of multipara with patulous 
external os, and can very rarely be found in the vaginal secretion of 
adult individuals. Another limitation of the value of bacterioscopic 
diagnosis is the rapid destruction and elimination of the gonococci in 
the affected tissue. Their numbers begin to diminish considerably after 
a short time, and those that remain may occupy the deeper layers of 
the epithelium or hide themselves in the recesses and folds of the 
cervical mucous membrane, so that they can no longer be demon- 
strated. But whenever the conditions are favorable, as during 
menstruation or the puerperium, or after severe mechanical irritation 
of the affected mucous membrane, the gonococci may suddenly begin 
to multiply again. Hence the failure to find gonococci in no sense 
excludes the presence of gonorrhea. Unless repeated examination after 
menstruation or during the puerperium, or after mechanical or chemical 
provocation, has failed to reveal the presence of gonococci, the diagno- 
sis of gonorrhea must still be considered; hence an attempt should 
always be made to demonstrate the microorganisms, if great importance 
attaches to the diagnosis. In medicolegal cases, and for the purpose 
of determining whether the secretions are capable of causing infection, 
a bacteriologic examination is indispensable. 

The urethral secretion is obtained by slowly passing the index 
finger along the canal from behind forward through the vagina, and 
exerting gentle pressure, several hours after the last urination. The 
cervical secretion is obtained directly with a loop from the cervical 
canal. (For the method of demonstrating the presence of gonococci 
see page 64.) 

The clinical diagnosis of gonorrhea is based on the presence of 
changes in the tissues that have been produced by the gonococci. These 
changes are not pathognomonic as they may also be produced by other 
microorganisms or irritants. Depending on the preponderance of the 
gonorrheal etiology in these tissue changes, they may be divided into 
positive, probable, and uncertain signs of gonorrhea. 

I. Positive signs of gonorrhea are tissue changes produced 
exclusively, or at least almost exclusively, by gonococci. 

(a) Recent purulent urethritis. Infection with other 
microorganisms, such as bacterium coli, is extremely rare. 



524 GYNECOLOGICAL DIAGNOSIS 

(b) Purulent processes in Bartholin's glands. These 
include recent adenitis in which pus can be expressed from the excre- 
tory duct; recent painful swelling of the gland due to occlusion of the 
duct and retention of pus; and abscesses of Bartholin's glands (suppu- 
ration of Bartholin's glands due to other micro5rganisms are so rare 
that they may be disregarded). 

II. Probable signs are tissue changes which may be produced 
by other microorganisms or irritants, but are much more frequently 
gonorrheal in nature. These include 

1. Old urethritis with moderately abundant, milky discharge 
and possibly periurethral infiltration. 

2. Small, hard, non-sensitive swelling of Bartholin's 
glands; cysts of Bartholin's glands; redness and a flea-bitten appear- 
ance of the mucous membrane surrounding the excretory duct (macula 
gonorrhoeica). 

3. Condylomata acuminata. 

4. Acute colpitis with profuse purulent secretion and marked 
swelling of the folds and papillae. 

5. Acute cervical catarrh, in which the secretion is chiefly 
purulent. 

6. Pyosalpinx. It has never been definitely determined that 
this may be due to some other infection, such as tuberculosis. 

III. Uncertain signs are tissue changes which may be due to 
gonorrhea as well as to some other cause. They include 

1. Slight milky secretion from the urethra and Skene's ducts. 

2. Redness appearing in patches at the top of the folds and 
caruncles of the urethra, in the neighborhood of the urethra, and 
around Skene's ducts. 

3. Colpitis maculosa (see page 517). 

4. Cervical catarrh with mucopurulent discharge. 

5. Suppurative endometritis. 

6. Hydrosalpinx. 

7. Adnexal tumors (see page 461). 

8. Perisalpingitis and perioophoritis. 

The importance of the bacterioscopic diagnosis is inversely pro- 
portionate to the value of the clinical signs. If positive signs are present, 
it is absolutely unnecessary and can do no more than confirm the clinical 
diagnosis. In the presence of probable signs it is a very welcome con- 
firmation of the diagnosis. When the signs are uncertain, a positive 
diagnosis is impossible without it. Unfortunately, however, bacterio- 
scopic diagnosis very often fails, even in cases which only present prob- 
able signs; and when the signs are uncertain and it is most needed, it 
almost always proves negative. We may say, therefore, that bacterio- 



SPECIAL DIAGNOSIS 525 

scopic diagnosis is usually unnecessary when it is successful, and in 
cases in which it would be necessary the results are rarely positive. 
Nevertheless, the method should be employed even for purposes of 
diagnosis alone. 

The only fact in the history that has any positive value is the 
occurrence of gonorrheal ophthalmia in one of the patient's children. 
The statement that the disease began with acute symptoms in the 
vulva and urethra immediately after coitus or after marriage, is strong 
presumptive evidence that the infection is gonorrheal, as is also the 
discovery of a recent gonorrhea in the husband. The fact that the 
patient has had a previous attack of gonorrhea is less significant. 



526 GYNECOLOGICAL DIAGNOSIS 



Microscopic Diagnosis of Endometritis. 

Without an accurate knowledge of the changes that occur in the 

inflamed endometrium, the microscopic diagnosis of material obtained 

by curettage is impossible. The inexperienced may mistake a benign 

alteration for a malignant, and vice versa, and the treat- 
Necessity of 
ExaminingUhe mcut may accordmgly prove disastrous to the patient. 

An injustice may be done to the patient by giving an 
incorrect prognosis, and the physician's reputation may suffer. Micro- 
scopic examination of scrapings should never be neglected, because the 
physician may mistake a benign condition for malignant changes, or 
vice versa, on the strength of his clinical examination. In many cases a 
positive diagnosis is impossible without microscopic examination. Endo- 
metritis of the uterine body, being the most important and most frequent 
form, will be treated first, and next in order cervical endometritis. 








Fig 303. — Scheme: (a) Cross-section of five normal uterine glands. (6) As the result of cellular multi- 
plication of the stroma the glands are forced apart and compressed. 

Corporeal Endometritis. 

The diagnosis of corporeal endometritis requires a knowledge 
of the composition of the normal endometrium, particularly, (a) the 
epithelium and its structures; and (b) the stroma. Both constituents 
may share in the inflammatory disease, either separately or together, 
or one rriore than the other. Inflammation of the epithelium and its 
structures (uterine glands — glandular endometritis), and inflammation 
of the stroma (interstitial endometritis), have this in common, that 
they depend in the main on a cellular multiplication. 

(A). In the acute or usual form of interstitial endometritis (e. 
inter glandular is) a considerable cellular multiplication often takes 
place. The number of stroma cells in the intervals between the glands 
may be increased to twice, three times, or ten times the normal. As 
a result of this the glands are forced apart, and compressed by the pro- 
liferation in the stroma, which completely surrounds them. The changes 



SPECIAL DIAGNOSIS 



527 



are most easily seen in cross-sections (Fig. 303). The acute cellular 
multiplication causes a thickening of the entire mucous membrane. 
In acute interstitial endometritis the increased stroma cells are 
seen in the microscopic picture as round elements completely filled 
by their nuclei so that no cell body can be seen, and closely packed. 
The glands, as compared with the normal 
(Fig. 303, h), appear compressed and forced 
apart. In the more chronic types of 
interstitial endometritis, or after several 
relapses, the accumulation of small round 
cells is replaced by the appearance of 
numerous spindle-shaped elements, giving 
the effect of cicatricial or fibrous tissue, 
or cirrhosis. In chronic interstitial endo- 
metritis the uniform arrangement seen in 
the acute process becomes irregular — 
strands of connective tissue alternating 
with round-celled infiltration (Fig. 305). 
In the exudative forms an albuminous 

fluid is found among the circular stroma cells, which becomes coagulated 
by the preliminary treatment of the microscopic specimen and presents 
a finely granular appearance (Fig. 306). In extreme cases of exudative 
endometritis the stroma cells appear wide apart, and the individual 
elements somewhat compressed and diminished in size. As the exudate 
does not take the stain, a striking difference is seen in the micro- 
scopic picture between interstitial 
endometritis with its abundance 




^'v;«*» 



Fig. 304. — Acute Intehstitial 
Endometritis. The proliferated stroma 
cells are closely packed; the glands appear 
diminished in number. 









Fig. 305. — Chronic Interstitial Endo- 
metritis. 







Fig. 306. — Interstitiai, Exudative 
Endometritis. A finely granular exu- 
date forces the stroma cells apart. 



of cells, and the exudative form; the former is dark red when alum- 
carmine is used, while the latter appears pale and translucent. 
In exudative endometritis the cells of the stroma are sometimes 
rendered even more prominent by the presence of the exudate; spindle- 
shaped and stellate elements with numerous processes are seen con- 
nected together, producing a fine meshwork. The exudative forms are 



528 



GYNECOLOGICAL DIAGNOSIS 









m^^. 




usually encountered with dysmenorrheic affections, the most typical 
picture being seen in the dysmenorrheic membranes. The connective 
Combination of tissuc structurc of the stroma formed by the processes of 
Various Forms, ^^le stroma cells (see under normal histology) may appear 
greatly thickened and fibrous; although in the main the same inflam- 
matory process always produces the same microscopic pictures in the 
.,.-._r.v ,-. endometrium, the interstitial cellular 

M^^^^S'^^^'-.'y^""''-:' '-'5^:. '.;:-!>, character may be more prominent 
7^^i'y<^'''' ' '''^^'^ in some cases than the exudative, 

'.•-'.'-ri^**...;'.4K^ and vice versa. 

In this connection so-called peri- 
glandular interstitial endome- 
tritis (comp.Fig.307 and Fig.264,a) 
is interesting. The interstitial tissue 
forms a marked cellular accumulation 
only in the parts immediately sur- 

FiG. 307. — Combination of pronounced inter- _ .. 

stitial, periglandular endometritis, with exudative rOUUClmg the glancis, WhllC the morO 
endometritis. , ,. , , ,., 

remote portions look more like exu- 
dative endometritis. If carcinomatous degeneration develops in the 
cellular layers surrounding the glands, which occasionally happens, a 
periglandular sarcoma is produced (comp. Fig. 264,6). In the microscopic 
section exudative endometritis often appears in patches, on account 
of the irregular alternation of cellular accumulation with exudate. 
In addition to the increase in the stroma elements and the exudate 
observed in the exudative form, the inflammatory process in inter- 
stitial endometritis produces a change in the shape of 
the stroma cells. Even in inflamed processes the 
stroma cell is a small round cell 
entirely filled with its nucleus, so that 
no part of the cell body is seen. The 
nucleus stains intensely. Occasion- 
ally in severe inflammatory condi- 
tions, and particularly in exudative 
processes (also when the glands in 
the mucous membrane perforate), the 
stroma cell becomes larger, the cell body more distinct, the nucleus 
slightly oval and not so intensely tingible, and often finely granular. 
^, „ This conversion of the stroma cell into an element with a 

The Stroma 

Cells Resemble dlstiuct ccll body is also found in glandular endometritis, 

Decidual Cells i i- • i i i • i ^ i • i • 

and often m the hypertrophied mucous membrane which is 
seen with myomata. The changes are most distinct in the superficial 
layers of the mucous membrane and, owing to their spindle shape, 
the cells often resemble decidual cells. 



■-i-f'ts. 



^5« 






/, ^ 



IS.' ■ - # 






Fig. 308. — Diagrammatic: 1. Normal stroma 
cell. 2. A cell from the lowest layer of a dys- 
menorrheic membrane. 3. Conversion of stroma 
cell into an element resembling the decidual cell. 



SPECIAL • DIAGNOSIS 529 

Similar changes are encountered in dysmenorrheic membranes, 
whereas in ordinary preparations interstitial endometritis with its 
small round cells is found in the vipper layers, the deep portions of the 
mucous membrane, where laceration has taken place, present small 
round oval elements with distinct cell body and circular nucleus. The 
cell body does not stain well. In rare cases the enlargement of the 
stroma cells is so great that the alteration 
cannot, at the first glance, be distinguished 
from that of pregnancy (endometritis ,-/ 0, 

inter stitialis deciduacellularis, Fig. ' ^^ '■ « ^ ^^ 

309). It may be exceedingly difficult to j \^ "/| ^■f^^K 

make a positive microscopic diagnosis in such . ■{! ", - '^ * ^, - »* 

a case. (See differential diagnosis under ft' A .''■»,-■ '^^'/-^ 

changes of pregnancy.) The fact that the •, ^.'.,^'M' 

elements are not always quite regular some- 
times makes the diagnosis of the non-gravid fig. 309.— The stboma cells 

, . 1_ J. • l'^ Dysmenorrheic Membranes 

alteration SOmeWnat easier. occasionally show a decidual change. 

Exudative interstitial endometritis more 
often than any other form leads to atrophy of the mucous membrane, 
instead of ending in recovery or going on to the chronic form. The 
mucous membrane becomes exceedingly thin, and the glandular struc- 
tures, as a result of the atrophy, are displaced in some senescentia 
places, and in others reflected on themselves, producing Prsecox. 
the picture of premature senility. Curettage, which may have been 
performed on account of distinct clinical symptoms for the special 
purpose of making a diagnosis in cases of this' kind, yields a very small 

quantity of material for examination. 
(B). In glandular endometritis a 
numerical increase in the epithelial 
cells, either those which cover the 
surface of the uterine mucous mem- 
„.LfrEP.V^7L:^lr"r™s^ra^in?^';:^ brane or those which form the uterine 

in the size of the fundus (6), or to an increase glancls wlthlu thc mCmbranC, takcS 
in tlie curvature (c). " ' 

place. The effect of this epithelial 
multiplication will be appreciated by studying the normal processes of 
epithelial proliferation. A number of epithelial cells (cylindrical cells. 
Fig. 310, a), since multiplication always takes place hori- -Yh^-^. ith li 1 
zontallv, cannot retain the same base, as, in order to Muitiphcation 

" . .in Glandular 

accommodate the increased number of cells, even if the Endometritis 
latter are somewhat narrower than the original normal Papiiiary change 
cells, the base must become larger and longer (Fig. 310, &). 
As the multiplication increases, a still larger base or foundation is 
required for the cells, which is effected by increasing the curvature 
34 




530 



GYNECOLOGICAL DIAGNOSIS 



v^ 



/( 



-^ 



of the base (Fig. 310, c). — At the surface of the endometrium the 
epithelial multiplication produces slight elevations and depressions 
which are, of course, accompanied by corresponding elevations of the 

mucous tissue — the surface be- 
comes slightly papillary. — In 
the uterine glands the epithelial 
multiplication takes place in all 
directions, and thus produces 
two different effects — the gland 
becomes elongated and the cross- 
section distinctly enlarged (Fig. 
312). — Macroscopically the epi- 
thelial proliferation produces an 
increase in the thickness of the 
mucous membrane; while in the 
microscopic picture, aside from 
the elongation, the increase in 
the width of the glandular lumen 
reduces the intervals between the glands (Fig. 312, c). If the curva- 
ture of the fundus is increased by the cellular multiplication, tortuosity 
is added to the elongation and widening of the glands. In the 
microscopic picture the tortuosity appears exceedingly uniform; the 
glands, which are in the main parallel, retain their relative directions 
even after cellular multipli- 





FiG. 311. — The Cellular Multiplication loads to 
elongation and widening Q>) of the normal glands (a) 
as well as to tortuosity (6, c). 



Glandular 
Endometritis 
with Tortuosity. 



,tS 



Oi" 



cation has rendered them 
tortuous (Fig. 
313). In addi- 
tion to simple 
tortuosity in the direction of 
a pendulum, so to s_peak, i.e., 
in one plane, a spiral, or, as 
it is usually called, "cork- 
screw" figure, may be pro- 
duced. The glands thereby 
appear to approach one 
another and the lumen also 
becomes wider as a result of 
the cellular multiplication. 
In the microscopic picture the glands may retain their parallel course 
for a long distance. Corkscrew glands are obviously not seen in the 
section in their entire length, since they do not occupy the same plane. 
When the epithelial proliferation is very great, the sinuosities of the 
glands are correspondingly greater and more numerous in a given 




Fig. 312. — Diagramm.\tic: As a result of cellular multi- 
plication the uterine gland (a) becomes wider and larger (6) ; 
tlie intervals between the glands apparently become smaller' 
(c) as compared with the normal {d). 



SPECIAL DIAGNOSIS 



531 




O 

D 



o 




Fig. 313. — The Proliferation of the Glandular Epi- 
thelium produces tortuosity of the glands; longitudinal section 
(a), cross-section (6). 



section of the structure. The tortuosity merges into the appearance 
of papillae, and the epithelial layers appear papillary; in longitudinal 
section, owing to the projections, they suggest the teeth of a saw 
(Fig. 314), while in transverse sections the picture is stellate or indented. 

All these changes are 
observed in glandular endo- 
metritis — elongation, dilata- 
tion, and tortuosity and saw- 
tooth formation. The two 
first usually affect the entire 
thickness of the mucous 
membrane uniformly, while 
in the saw-tooth formation 
the epithelial proliferation 
and the resulting papillary 
structure is seen only in the 
deeper portions of the gland, 
the upper portion remaining 
unchanged, rather thinner than normal, as though drawn out (Fig. 
314, a). The deeper portions of the mucous membrane often appear 
spongy (endometritis glandularis profunda). Of course 
tortuosity as well as the dilatation may also occur in the latter form. 
Glandular endometritis, which we have just described, like every 

other form of endometritis, 
consists in a cellular mul- 
tiplication which leads to 
dilatation, elongation, tor- 
tuosity, or the saw-tooth 
formation of the gland, 
and, since the change 
chiefly affects the gland 
itself, is called a hyper- 
trophy; or in other 
words, endometritis glan- 
dularis hypertrophica. 

In addition to the 
hypertrophy or enlarge- 
ment of the glandular apparatus, we also have hyperplasia, or an 
increase in the number of the glands. Hyperplasia rarely occurs without 
hypertrophy, although the latter may be present without the former. 
Hyperplasia is due to the same processes as hypertrophy, namely, 
cellular multiphcation; but in this case the gland tubes increase either 
by an actual increase in the glands, or by division of the glands, or by 







^ 



'^JK: 



m 



Fig. 314. — Proliferation of the Glandular Epithelium 
produces a saw-like appearance; (a) longitudinal section; (6) 
cross-section. 



532 



GYNECOLOGICAL DIAGNOSIS 



an extension of the glands beyond their normal site into the adjoining 
tissue ■ (muscularis) (Fig. SIS,,). In genuine multiphcation of glands 
the surface epithelium grows into the tissue (Fig. SISJ and forms new 

glands. This process of 




fN ^^,r'^.^.^^ 







Fig. 315. — The Proliferation of the Glandular Epi- 
thelium Leads to Hyperplasia: 1. The glands proliferate into 
the mucous membrane. 2. Diffuse ramification of the glands. 
3. They penetrate into the muscularis. 



hyperplasia is to be observed 
chiefly in polypoid prolifer- 
ation. The increase in the 
number of gland tubes is 
effected by evaginations of 
the gland tubes, by ever- 
sions along the course of 
the glandular shaft (Fig. 
SlSj), and these eversions 
may give origin to secondary 
eversions (secondary divi- 
sion). At first the aver- 
sions or evaginations are 
smaller than the original 
gland, and in sections ob- 
tained at the beginning of 
the process the groups of smaller gland openings are found near the 
inner lumina; in the place of one, we see many cross-sections of glands 
(Fig. 316). A third form of hyperplasia is produced by the glands' 
encroaching on the muscularis. The uterine glands, which in normal 
tissue usually cease abruptly at the edge of 
the muscularis, push their way in between 
the muscle bundles in the form of thin 
mucous glands, and this occurs even when 
the deepest portions of the mucous mem- 
brane are the seat of marked papillary 
(saw-tooth) proliferation. The uterine 
glands may extend from one to two centi- 
meters, or even farther into the muscularis. 
The glands are seen in groups in various 
portions of the section. 

In order to recognize the inflamma- 
tory processes it is very important to 
have the ability to distinguish between 
hypertrophic and hyperplastic conditions, 
although hypertroph}^ cannot always be sharply separated from 
hyperplasia. Most cases present sufficient differences to enable one 
to apply the two terms correctly to the two different forms of 
cell multiplication. 



O' 



o 





u 



o c 



..'^N 











u 






ns 



a 



Fig. 316. — Endometritis Glandu- 
laris Hyperplastica. The glands that 
undergo division at first present small 
division-glands. 



SPECIAL DIAGNOSIS 



533 



Uncomplicated forms of glandular endometritis, whether 
hypertrophic or hyperplastic, and pure forms of interstitial endometritis 
are rarely seen. The two are usually associated; either the epithelial 
and connective tissue portions of the uterine mucosa are 

Combinations of 

attacked together, or a glandular endometritis is super- various Forms 
added to an interstitial, or vice versa. The mucous mem- 
brane also appears thickened to the naked eye, even more so than in 
uncomplicated forms. Microscopically the intervals between the 
dilated glands are larger in the combined form than in pure glandular 
endometritis (Fig. 317, h and c). In a case of interstitial endometritis 
it may be assumed that the glandular apparatus is involved in the 
inflammatory processes if the glands are both forced apart and greatly 
dilated, or if tortuosity or saw-tooth formation is present. The term 
'endometritis inter stitialis glandularis' is then employed. 



I' '■' ,'■'-&' 





a 




"■'•^fesaasB^ 



Fig. 317. — Combination of Glandular and Interstitial Endometritis. In simple glandular endo- 
metritis (6) the glands seem to be closer together than in normal tissue (a); when it is combined with 
interstitial endometritis, the glands are forced apart (c). 

Another combination may be produced by the development of 
the exudative form — endometritis interstitialis glandularis 
exudativa. In the combined, as well as in the simple forms of 
endometritis the process may be found either in the super- 
ficial, or in the deeper portions of the mucous membrane. 
In glandular endometritis the deeper layers often appear 
more glandular, while the superficial present more inter- 
stitial changes — a condition which might be termed endo- 
metritis glandularis profunda interstitialis 
super ficialis. Above, the mucous membrane appears compact; 
while the deeper portions appear to be of a spongy nature, producing 
a similarity to decidua vera in the first month. Endometritis with 
a glandular change above, and an interstitial change below, has 
probably never been observed. 

In the combined forms of endometritis also the entire mucous 
membrane in the main falls a victim to the inflammatory process, and 
the microscopic pictures are, generally speaking, the same everywhere. 



Various 

Combinations of 

Interstitial, 

Glandular, 

Exudative, 

Deep, and 

Superficial 

Processes. 



534 



GYNECOLOGICAL DIAGNOSIS 



So far we have spoken only of acute or subacute inflammatory 
processes. Complete recovery may take place, with complete regenera- 
tion, although usually more or less irregularity remains both in the 
glands and in the interstitial portion. Dilatations may persist in 
the glands, and cellular increase may be arrested in the intersti- 
tial tissue. It is needless to say that relapses produce even greater 
and more extensive changes on the already impaired soil 
than were produced by the first acute inflammatory pro- 
cesses. The interstitial tissue in relapses shows more 
fibrous material and more spindle-shaped elements, giving the picture the 
character of chronic inflammation. This must be regarded as the result 
of incomplete regeneration and constitutes cicatricial contraction. 



Relapses of 

Inflammatory 

Processes. 





a 

Fig. 318. — (a) Endometritis Glandularis Interstitialis Ectatica {chronica). (5) Endometritis 
Interstitialis Glandularis Ectatica. In the latter the interstitial and in the former the glandular portion 
is chiefly involved (fungous endometritis). 

In chronic inflammatory processes, spindle-shaped, fibrous and 
cicatricial masses are produced in the stroma, causing cicatricial con- 
traction, kinking and constriction of the glands in the connective tissue 
portions of the mucous membrane. This leads to saccular 
dilatations containing mucus and fluid — ectasiae, or to 
absolute constriction — cysts. The dilatations encroach 
on the neighboring tissue, producing another alteration 
known as endometritis glandularis ectatica 
cystica interstitialis chronica (Fig. 318). If the irritation 
continues, and renewed cellular proliferation takes place, the cysts and 
dilatations may send out additional gland tubes by eversion, producing 
a structure with enormous rootlets (Fig. 319). The shaft of the gland 
may be covered by a whole series of ectasiae. 

Macroscopically the mucous membrane may become greatly thick- 
ened, from one-half to one, or even one and one-half centimeters, 



Chronic 

Inflammatory 

Processes 

Produce 

Ectasise and 

Cysts. 



SPECIAL DIAGNOSIS 



535 



Fungous 
Endometritis. 







Fig. 319. — Endometritis Ectatica 
Chronica. The dilated glands give off fresh 
proliferations — "root sprouts." 



projecting from the cut surface like a mushroom, and producing the 
picture of fungous endometritis. The glandular dilatation may reveal 
itself to the naked eye by the spongy (actually sponge- 
like), cribriform appearance of the mucous membrane. 
The presence of ectasise and cysts in the microscopic picture may 
decide whether the process is acute or chronic, as both changes are in 
favor of chronic or relapsing processes. 
In acute, as well as in chronic 
glandular endometritis, as in the case 
of the interstitial form, regeneration 
may lead to atrophy of the mucous 
membrane, which is converted into 
a thin, cicatricial layer of connective 
tissue containing a few remains of 
glands. The latter are narrow, irreg- 
ular in shape, and often in process 
of disintegration (endometritis 
atrophicans). It is practically 
indistinguishable from the senile or 
atrophic endometrium, and is very 
probably due to a precocious senility 
which has its beginning in the middle of the fourth decade of life. 
Another peculiar change occasionally seen in glandular endometritis 
is an apparent stratification of the epithelium, although the epithelial 
layer retains its regularity and is arranged in two uniform layers. On 
careful inspection this arrangement in two layers is explained by the 
peculiar grouping of the cells; one with a broad base and narrow upper 
extremity is found next to a cell with a narrow base and broad head- 
piece. In the elements with broad 
bases the nuclei are more basally situ- 
ated. This formation is the result of 
an attempt on the part of the cells 
to equalize one another as they increase 
(Fig. 320). In rare cases two layers 
of cells are actually present. Another 
change concerns the tingibiiity of the elements. While the nucleus still 
stains fairly well, the cell body is often quite pale, and a 
certain similarity to cervical epithelium is thus produced. 
A very interesting epithelial change, which is often observed in the 
saw-tooth formation, closely resembles the Opitz-Gebhard glands of 
pregnancy. The cylindrical epithelium becomes more round and piles 
up in several layers on the papillary ledges, becoming almost like 
squamous epithelium. The cells are grouped in bunches and their 




m^D//7 



Fig. 320. — Apparent Stratification (in 
Two Layers) of the Epithelium, produced 
by the mutual adaptation of the elements 
which accompanies marked proliferation. 



Change in 
the Tingibiiity. 



536 GYNECOLOGICAL DIAGNOSIS 

connections are loosened. Often the picture of desquamation is seen. 
The tingibility of the cells is diminished. It appears as if a metaplasia 
of the cylindrical epithelium took place, and the stratification may 
even arouse a suspicion of beginning carcinoma. 

The same picture is produced by the irritation of pregnancy, and 
this glandular change is therefore somewhat characteristic of pregnancy, 
but is in no sense pathognomonic (see Fig. 258). Similar changes in 
the glands — stratification, conversion of cjdindrical into squamous 
epithelium (metaplasia) — may occur in simple inflammatory processes 
also. Large portions of the gland wall, however, may retain their cylin- 
drical epithelium; the tunica propria is lost (comp. Fig. 259), suggesting 
the possibility of carcinomatous change. It is probable 
ProcieTin the that thc alteration is due to a necrobiotic process, char- 
toTtropiiy'''"^ acterized chiefly by enlargement, or by a peculiar swelling, 
of the glandular epithelium. An epithelial change which 
is found in large cysts, and in which the epithelium becomes shortened, 
cuboidal, or even like squamous epithelium, must be ascribed to mutual 
pressure and dilatation. 

It is exceedingly important to become familiar with these epithehal 
changes in order to avoid making an erroneous diagnosis of pregnancy 
or carcinoma. 

The changes that take place in the arteries and veins, so far as they 
may be judged by the microscopic picture, vary greatly. In many 
cases it seems as if the blood-vessels took no part in the process what- 
changesin evcr. The most marked inflammatory proliferations do 

the Vessels. ^^^ show a Corresponding increase in the blood-vessels; 

on the other hand, some preparations distinctly show dilatation of the 
vessels, and the thickness of the vessel wall may indicate the extent to 
which the arteries take part in the inflammation. They present a 
cirsoid, grapevine arrangement in the mucous membrane, the reflec- 
Hemorrhagic tious of thc vcsscls and the many adjacent transverse sec- 
Endometritis. tlous of the Same vessels producing a pretty picture in 
the microscopic section. In hemorrhagic endometritis numerous 
extravasations of blood in the superflcial layers are seen in addition 
to the dilatation of the vessels, like small apoplexies with bloody 
infiltration — pictures like those seen in menstruation, or even small 
subepithelial hematoma. 

The involvement of the lymph vessels is difficult to determine in 
microscopic preparations. In mild cases dilatation of the lymph vessels 
Changes in the ov clcfts may bc sccu, but nothing of the kind appears in 
Lymph Vessels. jj^Qre scvcrc cases. Occasionally in mahgnant cases the 
lymph vessels are thrombosed with a cleft-like arrangement, hanging 
together like a meshwork, and filled with small cells. 



SPECIAL DIAGNOSIS 537 

With regard to nomenclature, the designation should be such as 
to suggest at once to the hearer the corresponding macroscopic and 
microscopic picture. "We speak of an interstitial and glandular endo- 
metritis. When the two conditions are combined, the term endometritis 
interstitialis glandularis is appropriate, if the interstitial changes pre- 
dominate; or endometritis glandularis interstitialis, if the glandular 
changes are more prominent. Next we have, for special conditions, 
exudative, or even hemorrhagic, interstitial or glandular endometritis. 
Endometritis glandularis ectatica, cystica, hypertrophica or hyperplas- 
tica need no further explanation. Finally, the duration of the process 
is indicated by the adjectives acute, chronic, or subacute. 

When it is impossible to determine whether the interstitial or the 
glandular hypertrophy predominates, the term diffuse endometritis 
may be employed. 

In practice an accurate and descriptive scientific microscopic diagnosis is not as impor- 
tant as it is for the proper recognition of the condition. The point to determine is whether 
the disease is benign or malignant, whether treatment is necessary, and if so, what thera- 
peutic measures are indicated. It should not be forgotten, however, that in benign changes 
the prognosis with regard to the possibility of recurrence can be determined by the micro- 
scopic picture. Certain glandular ectatic hyperplastic forms of endometritis are exceedingly 
prone to recur in a very short time. If there is a marked tendency to repeated hemorrhage, 
total extirpation may be considered and may indeed be absolutely necessary, even when the 
microscope shows that the changes in the mucous membrane are benign. It is more partic- 
ularly in cases of benign but marked recurrences, wliich in themselves are an indication for 
extirpation of the organ, that a microscopic examination is very desirable, so that at least 
a definite prognosis may be given after the operation. In simple endometritis an absolutely 
favorable prognosis may be given after total extirpation, while after a radical operation per- 
formed on account of malignant degeneration the prognosis is always somewhat doubtful on 
account of the possibility of malignant metastases. Inspection alone, to determine the 
quantity of the scrapings obtained, can never decide the diagnosis, furnishes uncertain 
therapeutic indications and is of doubtful value in making the prognosis. 

In addition to the above-mentioned designations, a few' others are 
in use which are permissible only within certain limits. In so-called 
endometritis fungosa — a most descriptive term for the micro- 
scopic appearance of the mucous membrane — the hyper- Fungous 
trophied mucous membrane, one centimeter thick or more, Endometritis. 
projects from the cut surface of the organ like a mushroom; whole 
handfuls of material are often obtained by curettage. While the 
word "fungus" is macroscopically descriptive, a microscopic examina- 
tion is necessary to determine whether the condition is malignant; con- 
versely, an apparently fungous endometritis may seem to be clinically 
malignant and later may be shown to be benign by the microscope. 
After macroscopic examination an endometritis may be called ' fungous, ' 
for the sake of brevity. It should, however, be further characterized 
by the terms ' glandular interstitial, ' or ' hyperplastic, ' ' ectatic, ' ' cystic, ' 
'hemorrhagic,' or 'exudative interstitial glandular,' as the case may be. 



538 GYNECOLOGICAL DIAGNOSIS 

The adjective 'chronic' is not necessary if ectatic has been used, as 
multiple ectasise in themselves indicate that the process has existed 
for some time. 

The term 'adenoma' has often been used instead of glandular 
endometritis; but we are very apt to associate the notion of malignancy, 
or at least of something suspicious, with adenoma; hence the designa- 
Benign Adenoma tiou bculgn adcuoma — iu contradistinction to malignant 
of the Body. adcuoma— was introduced. Again the sufhx 'oma' usually 
indicates some form of tumor. Some authors use adenoma only for 
polypoid proliferations and polyps. The term 'benign adenoma' has 
not met with approval. 

A knowledge of the changes that are produced in the uterine 

mucous membrane as a whole is even more important for the microscopic 

diagnosis, which must be made by scrapings from the uterine cavity. 

The picture of the uterine mucous membrane as a whole 

Diagnosis of . , 

tiie Mucosa lias to be coustructeci from a small particle, in the scrap- 

Diagnost^of iugs particles obtained from the surface alternate with 
Scrapings. material removed from the deeper layers, and the micro- 

scopic picture contains horizontal and oblique, as well as transverse 
sections. A large number of sections must be prepared in order to make 
sure, for example, that all the particles are free from malignant change. 
If a preparation derived from the deeper layers of the mucous mem- 
brane is markedly glandular, while another from the same lot of 
scrapings is markedly interstitial, the diagnosis of endometritis 
glandularis profunda interstitialis superficialis, which is 
so common with myomata, will be made. 

The mistakes that are apt to be made in the microscopic diag- 
nosis of endometritis remain to be mentioned. Difficulties may arise 
from the great enlargement of the round cells of the stroma which 
accompanies inflammatory processes, and which gives 
Dia^no°istn them & more decidual character on account of the size and 
Changes of the ^j g distiuctncss of the cell body; it is often impossible to 

Stroma Cells. '' ' '• 

distinguish an individual cell from a stroma cell altered 
by gestation. In interstitial endometritis the enlarged cells are usually 
not so uniformly distributed throughout the mucous membrane as in 

the case of the genuine deciclua. In many cases they are 
ceUsRe°rmbie eucouutercd ouly in the superficial layers; nor are they 
Elements ^^ Uniformly converted into larger elements with large 

nuclei as in the case of the decidua; the irregularity which 
is seen here and there in interstitial endometritis decides the diagnosis. 
The intercellular substance also appears more homogeneous during 
pregnancy; the cells appear to be embedded in a soft mass, while in 
interstitial endometritis the intercellular substance appears more fibrillar, 



SPECIAL DIAGNOSIS 539 

and the cells lie loosely scattered in the tissue. In cases of interstitial 
endometritis in which the entire mucous membrane contains greatly 
enlarged decidua-like elements, the differential diagnosis between the 
changes of pregnancy and inflammatory products is sometimes very diffi- 
cult; but, as already stated, it is decided by the irregular structure 
which characterizes interstitial (deciduacellaris) endometritis. 

The large decidua-like cells of interstitial endometritis have also 
given rise to confusion with sarcomatous degeneration. The important 
points are the occasional conversion of the stroma cells 

_ ... . Differential 

into large cells with a distinct cell body, arranged in a Diagnosis in 
fairly uniform manner and, on the other hand, the atypical the Epithelial 
arrangement, which is characteristic of sarcoma. The ^™*^° ^' 

importance of avoiding this mistake is shown at once by the thera- 
peutic measures that are demanded by a diagnosis of sarcoma. The 
prognosis also is quite different. 

In the other cases, in which almost the entire uterine membrane 
shows decidual changes and the differential diagnosis between preg- 
nancy and inflammation is particularly difficult, there is less danger of 
confusion with sarcoma; here again the absence of the atypical, as 
compared with sarcoma, decides the question. 

Diagnostic difficulties may also be occasioned by the epithelial 
changes that occasionally take place in glandular endometritis. Whereas 
ordinarily, even when the inflammatory changes are very considerable, 
the typical arrangement of the epithelium in a single row 

. . Differential 

of cells is preserved, peculiar proliferations of the epithe- Diagnosis he- 
lium, piling up of the cells and stratification, may be in the stroma 
observed. The epithelial cells change their shape (meta- ^'^ arcoma. 
plasia); the tingibility is modified, and with this is not infrequently 
associated glandular enlargement. This peculiar epithelial change, 
which is observed in glandular endometritis with saw-tooth formation, 
may give rise to error in two different ways: The changes may be 
mistaken for the specific changes of pregnancy, since alterations of this 
kind occur quite frequently in gestation. In the second 
place — and this is what chiefly interests us here — the ^ofagnosts 

epithelial changes may be mistaken for carcinoma (com- mlTrlti" ^regl 
pare section on the Diagnosis of Malignant Diseases and nancy, and 

'■ o o Carcinoma. 

that on the Diagnosis of Pregnancy). Practice, and the 
fact that this peculiar epithelial change in the gland usually does not 
progress beyond a certain stage and never forms genuine cancer nests, 
which are sure to be produced in one place or another in cancer, 
serve to prevent the error. The finding of these changes should be a 
warning to the examiner to think of the changes of pregnancy, simple 
inflammatory processes, or a beginning carcinoma. 



540 



GYNECOLOGICAL DIAGNOSIS 



Errors may also arise when the arrangement in a single row of cells 
is apparently replaced by stratification in two layers in glandular endo- 
metritis (see Fig. 320). The condition is sufficiently clear in thin sec- 
tions, but the peculiar regularity and constancy of the two-layer arrange- 
ment, which does not go on to further stratification, is also of value in 
the differential diagnosis. It is a not inconsiderable point of distinction 
between glandular carcinoma of the cervix, especially malignant ade- 
noma of the cervix, and carcinoma of the body. In the body uniform 
arrangement in two layers is not direct evidence of malignant degenera- 
tion; whereas in carcinoma of the cervix a uniform arrangement in two 
or three layers, without going on to further stratification, does occur. 
The cervix has a carcinoma with a single layer of cells (malignant 
adenoma), a malignant adenoma with stratified cylindrical epi- 
thelium (two to three rows), and 
a malignant adenoma with strati- 
fied (two to three rows) more 
round or cuboidal epithehal cells 
(comp. Figs. 243, 244, 245). 

Oblique or flat sections 
through the glands may be 
responsible for a mistaken diag- 
nosis of cancer, as they form 
apparently solid nests of cells, or 
cellular structures, which appear 
stratified and therefore malignant 
(Fig. 321). Having one's attention called to the possibility, and famil- 
iarity with the pathogenesis, as shown in the scheme on page 526, will 
enable one to make the diagnosis. The irregularity in the arrangement of 
the cells and the peculiar round or oval boundary line are also suggestive. 
The papillary invaginations seen in glandular endometritis 
may be mistaken for beginning malignant adenoma, and the same 
mistake may arise through the closely packed gland tubes, when the 
glands are greatly hypertrophied. The deeper portion of the mucous 
membrane in glandular endometritis, which is known as the spongy 
portion, may give trouble if an insufficient number of sections are studied 
under too low a power. On the other hand, if the specimen is examined 
only under high power, the closely packed glands in the spongy portion 
may be mistaken for carcinoma. 

A well-marked endometritis glandularis papillaris with saw-tooth 
formation may be mistaken for beginning inverting malignant 
adenoma. In fact, it is difficult in the beginning to recognize invert- 
ing malignant adenoma, since it goes through exactly the same develop- 
ment as endometritis glandularis papillaris. The decision 




Fig. 321. — Oblique Section (flat section) through 
the fundus of a uterine gland. Tlie incision includes 
epithelial layers, but not the lumen. 



SPECIAL DIAGNOSIS 



541 



must be made by the staining properties of the epithelium. In 
mahgnant adenoma the staining is pecuHar and diffuse; in glandular 
endometritis there is a diminution in the tingibility of the epithelial cells. 
Finally, in inverting malignant adenoma the characteristic type of the 
gland is destroyed; whereas in endometritis the gland as an individual 
unit is preserved. In malignant adenoma no glands and no glandular 
lumina are seen, only epithelial cords arranged back to back. 
The everting form of malignant adenoma is also at first 
difficult to distinguish from hyperplastic glandular endo- 
metritis, but the occasional presence of beginning stratifi- 
cation may serve as an aid. If necessary, a number of 
sections must be examined. A source of error for the beginner is found 
in the peculiar pictures produced by cutting all the epithelial ledges that 
proliferate into the lumen of the gland — it looks as if glands were placed 
within glands. On more careful examination the glands are seen to 



Differential 
Diagnosis 
between Glan- 
dular Endometri- 
tis and Kvert- 
ing Adenoma. 





''V„,fM«"' 






/j^ 
^'^' 




C '^^f^'-'Si^^s^^'j's^. 



Fig. 322. — Gland with Papillahy Projection. In another section the projection remains as an isolated 
structure within the lumen (6, c); (d) circumscribed intraglandular (varicose) papillary proliferation. 



contain structures which are covered with cylindrical epithelium on 
the outside, and therefore merely simulate glands. The genesis of 
these structures is shown in the diagram (Fig. 322, a, h, c). Occasion- 
ally very great proliferations, so-called intraglandular excrescences 
occur, just as intracanalicular proliferations are sometimes intraglandular 
observed in other portions of the body, as, for example. Proliferations. 
in the mammary gland. By itself the picture might be taken for that 
of malignant degeneration; but if the changes occur singly, the prolif- 
eration is to be regarded merely as hyperplastic and not as a taalignant 
process (intraglandular verrucose proliferation) (Fig. 322, d). In this 
connection it is interesting to note that the malignant and benign pro- 
liferation at first follows the same development — malignant adenoma, 
like glandular endometritis, has its inverting and its everting stage. 
It has already been explained that heterotopia of epithelial 
structures is not necessarily a sign of cancer. Endometritis shows to 
what extent epithelial structures may pass beyond their original 
boundaries and penetrate deep into the muscularis without being 
malignant. On the other hand, the study of malignant tumors shows 



542 



GYNECOLOGICAL DIAGNOSIS 



:?. 



that heterotopia is not absolutely indispensable for the diagnosis, 
particularly in the early stage. Carcinomata and sarcomata are seen 
which do not extend beyond the limits of the mucous membrane 
(comp. also the S3aicytial infiltration of the uterine muscularis). 

As yet inflammatory endometritis has been classified only on 
anatomic or histologic grounds. An etiologic classification is not prac- 
ticable. There is but one form in which the structure itself points to 
a definite microorganism, namely, tuberculous interstitial endometritis. 

Instead of circumscribed 
inflammatory foci, the micro- 
scopic picture shows giant 
cells with parietal nuclei, 
surrounded by circumscribed 
areas of round cell infiltration 
(Fig. 323, b). It is not alwaj^s 
possible to demonstrate the 
tubercle bacilli by staining 
methods, but the histologic 
picture is sufficient evidence 
of the tuberculous nature of 
the affection. These circum- 
scribed inflammatory foci 
may be quite numerous in 
the mucosa. It is worth 
noting, and will be referred 
to again, that after curet- 
tage and after a microscopic 
diagnosis of tuberculosis has 
been made, a quite remark- 
able improvement in the general condition of the patient sometimes 
occurs in cases which had been apparently unfavorable. 



^'' 



a^"^^^/':: 






m 



fiijfy^^i^^^i^:^. :h'Wr 






■iK'-- 



^0 'WM^^ 



Fig. 323. — Tuberculous Endometritis, (a) Greatly 
inflamed and infiltrated mucous membrane containing paler 
foci in which the giant cells are seen. (6) The foci under 
higher magnification. 



The chief distinction between corporeal and cervical endome- 
tritis is that the former is more productive, while the latter is secretory. 
Indubitable inflammatory proliferation and infiltration of the stroma 
Cervical ^Iso occur in the cervix. The inflammatory process may 

Endometritis. begin at the surface around the glands, and we may speak 
of periglandular cervicitis. In addition to the interstitial forms, 
epithelial multiplication, numerical increase of the 
glands, either hj dipping down of the superficial epithelium or by 
ramification of the trunk (comp. Fig. 246, adenoma of the cervix, in the 
section on The Malignant Diseases of the Uterus) are undoubtedly seen. 



SPECIAL DIAGNOSIS 



543 



,<2^?l 






K 



The epithelial structures, like the erosion glands of the vaginal portion, 
may penetrate a considerable distance into the tissue. The tendency 
to respond to an inflammatory irritant by profuse secretion, which char- 
acterizes the cervix, leads to a much greater production of ectasia or 
dilatation than in the case of the body. The dilated and constricted glands 
form visible products, — vascular structures, from the size of a pea to that 
of a cherry — in the vaginal portion, 
filled with a tenacious, glairy or 
slightly milky mucus, called ovula 
Nabothi or follicles (Fig. 324). 

Proliferation of the surface epi- 
thelium associated with proliferation 
of the connective tissue gives the 
cervix a slightly papillary, velvety 
appearance (corresponding to the 
papillary erosion of the vaginal 
portion — Fig. 325) — endometritis 
cervicalis papillaris. Polypoid pro- 
liferations are often 
seen, frec^uently in- 
cited primarily by the 
follicular proliferations 
of the glands (follicu- 
lar polyp and mucous 
polyp). Mucous polyps 
which contain large 
cystic spaces are called 
follicular polyps. They 
often exhibit consider- 
able glandular prolif- 
eration in their interior 
and new formation of 
glands on the surface, 
which is often distinctly papillary. The metamorphosis that takes 
place in the epithelium — epidermidalization — which has been 
described at length in connection with erosion, is extremely interesting. 

Genuine ulcers, such as are not observed in the mucosa of the 
body, may produce marked hemorrhages in the cervix as well as in the 
vaginal portion, as the inflammatory infiltration is often 
very vascular. As in the vaginal portion, a simple ulcer 
may contain erosion glands; but in the main ulcer and erosion are two 
separate conditions (vaginal and cervical structures). If there is clini- 
cally a suspicion of carcinoma in this condition, it can be laid only by 




Fig. 324. — Follicular Erosion (Ovul.i N.^bothi). The erosion 
glands, like cervical glands, dilate and form follicles. The follicles in 
the mucous membrane represent the beginning of ' follicular polyps. ' 
(a) General view; (6) somewhat enlarged. 



Cervical 
Ulcers. 



544 GYNECOLOGICAL DIAGNOSIS 

means of a histologic examination, showing the changes of inflammatory 
infiltration. Whether the latter is due to syphilis or tuberculosis cannot, 
however, be decided. In the beginning it may be difficult to distinguish 
a malignant adenoma from proliferation and hyperplasia of the cervical 
glands; the change in the tingibility of the epithelial cells in a case of 
this kind is a very important diagnostic point, as has been already 
stated. If the epithelium of the cervical erosion stains diffusely 
and the characteristic position of the nucleus is lost, there must be a 
strong suspicion of beginning malignancy even in the absence of strati- 
fication. If the latter change has taken place and there is a uniform 







^n^ 



-v" i- l\ .1 1' '/n \ J/ ^'^ 



o 




Pig. 325. — Papillary Erosion. Papillary excrescences grow out from the erosion glands and ultimately 
reach the surface. In a similar manner papillary proliferation is also produced at the surface. 

extension of the epithelial proliferation (adenoma malignum cervicis), 
the diagnosis is clear. From the standpoint of differential diagnosis it 
is important not to mistake any epithehal change in the polyp for car- 
cinoma (see above), since non-malignant changes of the epithelium after 
the manner of epidermidalization occur quite frequently in polypi to a 
considerable depth (down to the base of the polyp). 

The cervical endometrium, like that of the uterine body, undergoes 
senile atrophy which affects all the constituents of the membrane; the 
projecting atrophic folds may contain whitish deposits of calcium salts. 



SPECIAL DIAGNOSIS 545 



Diagnosis of Malformations of the Internal 

Genitalia. 

The most important malformations in the adult genitalia are those 
of the uterus and vagina. Developmental disturbances of the ovaries 
and tubes are so rare and have been studied so imperfectly and, on the 
other hand, the clinical sjnnptoms which they produce are so vague, 
that they cannot be recognized with certainty. As for the malforma- 
tions of the external genitalia, they will not be considered in this con- 
nection because they are easily recognized by inspection, and their 
ciiagnosis requires no detailed discussion. 

The ciiagnosis of these malformations presupposes a knowledge 
of the development of the female genitalia, and so much of it as has 
a bearing on these malformations will therefore be briefl)' given. 

The internal genitalia develop from the germinal glands and 
the two ducts of Midler, the Wolffian duct being represented in the 
adult only by an insignificant rudiment. The germinal glands develop 
on the inner side of the two Wolffian bodies, which lie on each side of 
the fetal vertebral column, while the Wolffian ducts pass downward 
to one side of the column. The ducts of Miiller are in relation with the 
proximal portion of the AVolffian body and grow from this point down- 
ward along the venti'al wall of the Wolffian duct, the upper portion to 
the outer, and the lower portion to the inner side of the duct. The two 
portions gradualh^ approach one another, so that at the lower extremity 
they are in close contact. Accordingly they follow a convex course, 
with the convexity directed downward, which is accentuated by the 
fact that the upper end descends along with the ovary in the descent 
of that organ. The lower extremity of Miiller's duct opens into the 
urogenital sinus. About the middle of their course the ducts of Miiller 
first become fused, and this fusion graduall}^ progresses from above 
downward, the upper extremity remaining separate. The septum 
between the fused portions gradually disappears and a common canal 
is thus formed. The ducts of Miiller form the tubes, uterus, and vagina; 
the upper paired segments form the tubes, while the intermediate and 
distal portions unite to make the single uterus and vagina. The bound- 
ary between the double and single portions corresponds to the attach- 
ment of the round ligament. The fetal germinal glands form the ovaries; 
the proximal portion of the Wolffian duct in the adult is represented 
by the rudimentary epoophoron (parovarium), the distal portions by the 
so-called ducts of Gartner, traceable down into the region of the cervix. 

35 



546 GYNECOLOGICAL DIAGNOSIS 

The external genitalia develop from the median genital 
eminence and the two lateral genital folds, which form the genital 
furrow. Between the genital folds is the orifice of the cloaca which, as 
the perineum develops, divides into the urogenital sinus and the anus. 
The genital eminence becomes the clitoris, the two lateral genital folds, 
the labia majora; the genital furrow becomes the rima pudendi, 
the two lateral edges of which are formed by the labia minora. The 
perineum is formed by the fusion of the two genital folds in the median 
line, and the rectovaginal septum grows down like a spur from above 
toward' the perineum. 

The point where the developmental sphere of the duct of Miiller 
meets the external skin corresponds to the hymen, which is formed by 
the lower blind extremity of the duct of Miiller and represents the 
boundary between it and the urogenital sinus. 

Classification. The systems devised by Fiirst, Nagel and v. 

Winkel, which are based on the various stages of development of the 

internal genitalia, are of no value for diagnostic purposes. Without 

doing violence to the anatomical conditions, malforma- 

Classification. . ,. ,. . , t-ii-,, 

tions may tor diagnostic purposes be divided into two 
separate groups. The first includes all cases of insufficient development 
of the internal genitalia; the other embraces the double formations. 
The reason for including all cases of imperfect development in one 
group is that the subjects consult the physician for functional disturb- 
ances, amenorrhea, sterility, molimina and impotentia coeundi. Given 
these disturbances, therefore, the cause must be sought in some develop- 
mental anomaly, and its nature must be determined. Double mal- 
formations, on the other hand, which constitute the second group, are 
only found accidentally in otherwise healthy women, and give rise to 
definite symptoms only when they are associated with atresia. 

I. Diagnosis of Imperfect Development of the Uterus 

and Vagina. 

This group embraces all cases of total absence, of rudimentary 
anlage, and deficiency of the uterus, associated with absence or defi- 
ciency of the vagina. The tubes and ovaries in most cases are fully 
developed, and the external genitalia are usually normal; hence fusion 
of the ducts of Miiller is normal and their development only is deficient; 
while, on the other hand, the metamorphosis of the genital glands and 
the development of the external genitalia are normal. In these cases 
the physician is usually called upon to find out the cause of an absolute 
amenorrhea, or rarely of sterility, or impotentia coeundi. 

The examination is begun by inspecting the vulva; the hair 
and the development of the greater and lesser labia, as well as that of 



SPECIAL DIx4GNOSIS 547 

the clitoris, must be noted. In most cases the external genitalia are 
absolutely normal, even when the development of the uterus and vagina 
has been very much interfered with, because the external genitalia 
have nothing to do with the development of Miiller's 
duct. The shape of the labia minora is investigated for the 
presence of bodies resembling testicles, as women presenting the above- 
mentioned symptoms are sometimes male hermaphrodites (see page 
549) in disguise. The urethra must also receive attention because, 
although it does not take part in the malformation, it sometimes becomes 
greatly dilated by attempts at coitus when the vagina is absent, so that 
the finger can be easily introduced into the bladder. 

The condition of the vagina depends directly on that of the 
introitus; if the latter is completely occluded, either the vagina may be 
absent altogether, or in mild cases there may be merely atresia of the 
hymen with a normal vagina. The distinction is most 

• • TTTi 1 Vagina. 

easily made by means of a rectal exammation. When the 
vagina is entirely absent, only a few thin fibrous cords at most are felt 
instead of the vaginal canal. The rudimentary vagina may be more 
easily found by introducing a catheter into the bladder; if there is 
merely occlusion of the hymen, and the genitalia are otherwise perfectly 
developed, a hematocolpos is always present and is recognized on 
inspection by marked bulging of the closed hymen and a bluish color, 
due to the presence of menstrual blood. Through the rectum, or by 
bimanual examination, it is felt as a tense approximately spherical 
tumor filling the entire pelvis as far as the introitus, while above the 
uterus, which is also dilated, and possibly a bilateral hematosalpinx 
are found. In rare cases the vagina behind the hymeneal atresia is not 
filled with blood and is recognized by moving the two walls against one 
another. If the introitus is open, the finger is introduced and the length 
of the vaginal tube is determined. Quite often a short cul-de-sac is 
felt instead of the vagina. In virgins it is extremely short because it 
corresponds to the short urogenital sinus; but if coitus has taken place, 
it may be considerably elongated and dilated and may almost simulate 
a normal vagina. The condition of the vagina above the cul-de-sac 
can only be determined by a rectal examination with a catheter intro- 
duced into the bladder. An accurate examination is always necessary 
if an operation for the purpose of opening the vagina is contemplated. 
If the vagina is present and of normal length, the vaginal portion 
must be examined. 

Examination of the uterus is the most important part of the 
diagnosis; accurate palpation is possible only under anesthesia, by 
introducing two fingers into the rectum and palpating through the 
abdominal walls with the other hand. Small rudiments are much 



"to 

I 

Uterus. 



548 GYNECOLOGICAL DIAGNOSIS 

more easily found by introducing a catheter into the bladder. As 
the rudiments are in relation with the posterior bladder wall, palpation 
should be begun in the median line from the symphysis toward the 
promontory. If nothing is found, the investigation is 
continued to each side, and as the rudiments in this region 
usually run transversely across the pelvis, palpation is performed by 
keeping the fingers in close contact and moving them from before 
backwards, as is done in examining the tubes. If possible, the ovaries 
and round ligaments should also be palpated. 

Although on careful examination no vestige of a uterus running 
either in a sagittal or in a horizontal direction, or even fibrous cords 
may have been discovered at the normal site of the organ, the diagnosis 




Fig. 326. — "Uterus Rtjdimentaris Bipartittjs (as seen at laparatomy). J^. (Original.) Merely a 
transverse rudiment with two lateral, enlarged eoruua; the right adnexa are normal; on the left side there is 
a small ovary and two small cords corresponding to the tubes. 

of complete absence of the uterus is nevertheless not justi- 
fied because there may be anatomical rudiments that have escaped 
clinical examination, or because rudimentary cornua may have been 
mistaken for tubes; or finally because the individual may be a male 
hermaphrodite. Absence of the uterus is extremely rare in adult women. 
If, however, a rudiment is distinctly found in the region of the uterus, 
it may present various forms. In some cases there may be felt in the 
median line at the site of the uterus a small, round, firm body, or merely 
a slight thickening of the cellular tissue, which extends below to the 
cul-de-sac of the vagina, or is connected with the fibrous bands which 
correspond to the rudimentary vagina. This median uterus gives off 
rudiments which pass out laterally toward the pelvis and usually repre- 
sent thin round, or flat solid cords that feel like tubes, with a swelling 
in the lateral portion on one or both sides corresponding to a greater 



SPECIAL DIAGNOSIS 549 

accumulation of muscle tissue, sometimes with the formation of a cavity. 
These lateral swellings always represent the lateral extremity of the 
uterine rudiment, and form a welcome boundary between the rudiment 
and the tubes (Fig. 326). They are very often mistaken for ovaries, 
an error which is best avoided by demonstrating the presence of the 
ovary alongside of them. Whether the uterine rudiment contains a 
cavity is determined by the presence or absence of hematometra, when 
the mucous membrane is capable of functionating. The round liga- 
ment is a positive anatomic sign of the boundary between the uterus 
and the tube, but on account of the difficulties of palpation it is not 
available clinically. After the presence of a uterus has been deter- 
mined, the ovaries should be investigated and are always found in 
uterus rudiment aris bipartitus, the commonest form of rudi- 
mentary uterus. In many cases normal ovaries are present on each side; 
in other cases they are defective, depending on whether the duct of Miiller 
alone, or with it the germinal gland has been arrested in its develop- 
ment. The degree of development of the ovaries is determined by 
their size and functional activity, by the regularly or irregularly 
occurring molimina. The condition of the tubes can very rarely 
be determined clinically. 

Finally, the shape of a uterus that is too small in all its dimensions 
can be recognized through the vagina or by bimanual rectal examina- 
tion. Two varieties, which can be differentiated by palpation, are 
described: In one the cervix is much longer and thicker than the body, 
which represents no more than a fourth or a third of the entire length 
of the organ, with very fine, often membranous walls (uterus 
foetalis). In the other form the uterus has a total length of about 
4 to 5 cm.; the shape is like that of a normal uterus with an arched 
fundus, and the cervix is not out of proportion (uterus infantilis). 
In these cases the behavior of the vaginal portion gives a clue to the 
condition of the uterus. In uterus foetalis it is usually entirely 
absent, and instead of an external os there is merely a small opening in 
the vaginal vault. In uterus infantilis the vaginal portion is 
indicated, although very small, and at its apex is seen the external os. 
By means of the sound the presence of a cavity within the uterus is 
determined, and from its length the degree of developmental disturb- 
ance can be estimated; after that the size and position of the ovaries 
are investigated. 

Differential Diagnosis. Confusion most frequently arises 
between deficiency of the uterus, or rudimentary uterus, and pseud o- 
hermaphroditismus masculinus externus, i.e., a male indi- 
vidual with female external genitalia. Mention is made in the literature 
of a number of men deformed in this way, who contracted matrimonial 



550 



GYNECOLOGICAL DIAGNOSIS 



alliances as women because at birth they were pronounced females on 
the strength of the external genitalia. The appearance of the vulva 
is of no value, as it may be absolutely female in male hermaphrodites. 
The clitoris, labia majora and minora and even the introitus may be 

normally formed. A completely developed vagina is some- 
foditilmus"'''^^" what more rare in such individuals, if the deceptive cases 
Extemii"'' ^^^ which the urogenital sinus has been enlarged by attempts 

at coitus are excluded. The diagnosis is determined by 
the cojidition of the sexual glands. The ovaries are found in their 
normal situation, while the testicles descend into the greater labia, 
where they may be distinctly felt as movable bodies (Fig. 327). The 
appearance of the vulva in these cases is often verj^ misleading as 
it seems to establish the female sex of the individual beyond a doubt. 




Fig. 327. — Pseudohermaphroditismus Masctoinxis Externus. P.-F. }^. (Original.) The 
ovaries are wanting (the testicles are embedded in the labia majora). On each side the vas deferens passes 
downward and inward from the internal ring; its junction with the bladder cannot be palpated. In the 
median line in front the urethra is felt. There is no vestige of prostate or uterus masculinus. 



Accordingly the testicles are not infrequently mistaken for ovaries and 
a diagnosis of hernia of the ovaries is made. In the first place 
this is a rare condition, and in the second place, the labium in such cases 
does not contain a testicle and epididymis. In cases of bilateral cryp- 
torchism the diagnosis is very difficult. The uterine findings are likely 
to be misleading, as a masculine uterus often gives the impression of a. 
small rudimentary organ; the larger the rudiment, however, whether 
it lie in the sagittal or transverse direction, the greater the probability 
that the individual is a woman. The bodily habit, the voice, sexual 
sensations, and the discharge of fluid during sexual excitement, are of 
no value for the differential diagnosis, because they may be either entirely 
absent or present in a perverted form. 



SPECIAL DIAGNOSIS 551 

II. Diagnosis of tlie Double Formations of tlie 
Uterus and Vagina. 

Double formations of the uterus and vagina are due to the failure 
of the ducts of Miiller to unite and form a single uterus and vagina, the 
structures remaining double and developing each into a complete vagina 
or uterus, or a segment of the organs. The degree of double formation 
may be extremely variable. The entire genital canal or only the upper, 
or the lower segment, or both at the same time ma}' be double, while 
the cervix usually remains single. 

These malformations are always discovered by accident; for, aside 
from the cases of retention in an occluded half, they produce no symp- 
toms and are therefore not suspected. 

In some cases a double vagina is discovered at the examination 
by the fact that each of the two fingers enters a separate vagina; or 
by finding a different condition at the vaginal portion in the two vaginas. 
Double vagina is apt to be overlooked when one half is 
rudimentary and the septum is near the vaginal wall, 
unless there is an opening below and the rudimentary half can be demon- 
strated with the sound. A partial septum is much more easily recog- 
nized if situated below, because the lower border can be felt. Once the 
suspicion of divided vagina has been aroused, it is confirmed by finding 
a double introitus or by discovering a septum between the two fingers. 
A torn septum is more difficult to recognize; it is usually situated at 
the posterior wall and projects as a piece of mucous membrane from the 
vulva. In other cases a mere suggestion of a septum in the form of a 
slightly thickened prominence in the median line of the anterior or 
posterior wall is found. The existence of double vagina is strong pre- 
sumptive evidence of the same formation in the uterus. 

Vaginal Portion. In rare cases, two completely formed vaginal 
portions, each with a normal external os, are found. The vagina is 
always double, each half containing a vaginal portion, except in very 
rare cases in which the lower portion of half of the vagina is rudimentary, 
when both vaginal portions are found in the normally formed vaginal 
half. The double vaginal portion always points to very complete divi- 
sion of the uterus, either uterus didelphys or uterus bicornis 
duplex. In most cases the vaginal portion is single, and the division 
begins higher up in the cervix; the latter is usually broad and occasion- 
ally divided in the median line by a vaginal septum or raphe. Accord- 
ingly the external os may be single (uterus bicornis Double 
uniforis) or double; this anomaly of the portio is usually ^ agmai Portion, 
associated with well marked double formation of the uterus, with the 
exception of the cases of uterus septus biforis — a single uterus 



552 GYNECOLOGICAL DL^GNOSIS 

with a double external os. If the external os is single and wide open, 
as in multipara? or during parturition and in the puerperium, the finger 
may be introduced for the purpose of determining whether the cervix is 
single (uterus bicornis unicollis), or whether it is divided by a 
septum coming down from above, and how far the septum extends 
downward. If during parturition or in the puerperium the vaginal por- 
tion is found to be incompletely formed, there is danger of mistaking 
the lower extremity of the divided cervix for a double external os. 
The greatest significance obviously attaches to double forma- 
tion of the uterine body and the adjoining portion of the cervix. 
This maj^ be determined either by bimanual examination with two 
fingers through the rectum, under anesthesia, or by the 

Double Uterus. . . ^ • , i , t ^ ci 

introduction ot two sounds into the two halves of the 
uterus. In the mildest cases of double formation the uterus is single, 
although greatly broadened at the fundus and somewhat retracted in 
Uterus 'the middle, with occasionally a median longitudinal furrow 

Arcuatus. (utcrus arcuatus). Although externally there may 

be merely a suggestion of duplication, the cavity maj^ either be single, 
with only a small spur at the fundus corresponding to the retraction, 

or divided from above into two halves by a septum (uterus 

Uterus Septus. , . . , , . » , . 

septus), ihis septum is at once demonstrated it during 
parturition, abortion in the puerperium, or after dilatation the finger 
can be introduced into the cavity. One feels the free border of the 
septum, and it is easy to determine by entering both cavities how far 
down the septum extends. If the cervix is closed, the presence of a 
double cavity is demonstrated by introducing the two sounds at the 
same time, and finding that they do not touch each other in the divided 
portion. If the septum does not extend the entire length of the organ, 
we speak of uterus subseptus, and this again is subdivided into 
uterus subseptus unicorporeus, unicollis and uniforis, 
depending on whether part of the corporeal cavity, or only the cervix, 
or only the external os is single. 

But if on palpation the body of the uterus is found to be distinctly 
divided from above, the condition is either uterus bicornis or 
uterus didelphys. If the two cornua are close together they are 
readily recognized as the two halves of the divided uterus; but if they 
unite below at a very obtuse angle, there is a tendency to mistake one 
cornu for a subserous myoma on account of its pedunculated connec- 
tion with the other. The oblique position of the uterus, it is true, points 
to a double formation; but by introducing the sound, and by palpating 
the adnexa and noting their consistency, it is usually possible to dis- 
tinguish the two structures (see page 278). After both cornua have 
been positively recognized, the extent of the division must be deter- 



SPECIAL DIAGNOSIS 553 

mined. If the two cornua unite at the internal os, the condition is a 
uterus bicornis infrasimplex (Fig. 328). The cervix is usually 
thicker and broader and may be more or less completely divided by a 
septum from above (uterus bicornis uniforis, uni- uterus 

collis). But if two cervices are found by palpation, the Bicorms. 

anomal}^ is a uterus bicornis duplex if their median surfaces 
are barely connected, and a uterus didelphys if the two cervices 
are also completely separated and held together only by uterus 

loose connective tissue. The lower down the duplication Dideiphys. 

extends, the more easily it is recognized, and two completely divided 
uteri can be palpated with as much accuracy as two separate organs; 
nevertheless the diagnosis is much easier if two sounds are intro- 




FiG. 328. — Utehus Bicornis Infrasimplex. P.-F. %. The left cornu is large, 9 cm.; the right 
smaller, 6.5. cm. The division extends to the region of the internal os; the septum in the cervix extends 
almost to the widely dilated external os. 

duced for the purpose of stiffening the two uteri. The distinction 
between uterus didelphys and uterus bicornis duplex is often by no 
means easy, on account of the difficulty of determining the width of 
the connection between the two, especially if during parturition the 
connective tissue is very much softened. The width of the connection 
is determined most easily by moving the uteri against one another. 
The uterus is often twisted in these cases of double formation, with one 
cornu, most frequently the left, rotating forward and the other backward. 
If, instead of uniform development of the two ducts of Miiller 
into the uterus and vagina, one of them develops normally and the 
other remains undeveloped or rudimentary, a different kind of clinical 
picture is produced. On one side there is a uterus (uterus uni- 
cornis) and on the other side nothing, or merely a rudimentary cornu, 
often associated with an equally rudimentary vagina. The diagnosis 
of this condition is usually made only by accident; but if a pregnancy 



554 GYNECOLOGICAL DIAGNOSIS 

develops in the rudimentary cornu, or menstrual blood or pus is retained 
the resulting conditions may be most grave and even threaten the 
patient's life, hence the diagnosis is of the greatest importance (see 
below and page 174). 

The diagnosis of a simple uterus unicornis is based on the 

shape and position of the organ. As it is developed from a single duct 

of Miiller, the uterus is accordingly narrower, thinner, long drawn out, 

without a true fundus, and very slender where it joins the 

Uterus Uiiicor- •,i,i •• pit 

nis with Rudi- tube, in accordance with tlie position or the duct the 
organ is oblique, or almost transverse, and there are no 
adnexa on the median side; if there is a rudimentary cornu on the 
other side, the diagnosis will depend on its degree of development. 
A thin, thread-like cornu is difficult to feel, except the swelling which 
is occasionally found at the lateral extremit)^, but which may again 
be mistaken for an ovary. If it approximately attains the thickness 
of a normal tube it may be palpable if the abdominal walls are not 
too thick; the depression is always immediately above the external os. 
If the rudimentary cornu is thicker than the tube, it can be felt like 
a subserous m3^oma projecting by a pedicle from the inner margin of 
the uterus; if there is a communication with the uterine cavity, and 
the sound can be introduced into the rudimentary cornu, it is evidence 
that the latter contains a cavity. When the connecting piece is massive, 
the presence of a cavity in the lateral portion of the cornu may be 
assumed if pregnancy or retention tumors develop in it. 

The importance of this double formation is increased if the 
menstrual blood, or mucoserous fluid, or pus (hemato-, hydro-, 
pyo-metra or -colpos unilateralis) forms behind the closed 
extremity or in a closed portion of a double vagina. The 
Tumor^'Tna symptoms produccd hj the tumors are so severe that a 
Uterur"*'''^^ physician is always consulted. On the whole, these 
conditions are extremely rare. The diagnosis of these 
retention tumors is extraordinarily difficult and is made only if the 
ph5'-sician happens to think of them. It depends on the demonstra- 
tion of a fluctuating tumor associated with a double uterus; but 
the diagnosis of the malformation is rendered more difficult by the 
fact that, as the fluid accunuilates, the tumors lose all the properties 
of a uterus or vagina. If onh^ a single sign of double formation is found, 
either in the uterus above, or more frequently in the vagina, the exist- 
ence of a hematometra or pyometra in the rudimentary horn becomes 
extremely probable. The shape of the tumor is approximately round 
or oval, and if the wall is not too thick, the consistency is C5'stic. Its 
position alongside of the functionating uterus depends on the extent 
of the division; if a tumor forms in the lateral portion of the rudimen- 



SPECIAL DIAGNOSIS 



taiy cornu, its distance from the uterus will be so great that the 
examiner will always think first of an ovarian tumor. A positive diag- 
nosis is hardl}' conceivable unless the origin of the corresponding tube 
and ovar}' is found on the external surface, or the symptoms are very 
severe; on the other hand, retention tumors in a uterus bicornis or 
uterus didelphys are much more closely connected to the sound half. 
The width of the connection depends on the kind of double formation 
present. In uterus didelphys the outline of the open uterus is most 
easily determined; in uterus bicornis the tumor is usually so close that 
the angle between the two cornua is difficult to demonstrate; in uterus 
septus the retention tumor occupies a portion of tli(> uterus itself, and 
the empty half can be recognized only with the sound. The physical 




Fig 329. — Uterus Bicornis and Vagina Septa with Occlusion op the PtiGirr Vagina. P.-F. J^. 
(Original.) Tlie vagina is constricted on the riglit by a fluctuating tumor half as large as a man's head, 
which extends almost to the introitus; on the dome of the tumor the right cornu can be felt running almost 
transversely; the left cornu can be distinctly outlined. After incision the vestiges of the external and the 
internal os can be felt in the hematocolpos sac. The adnexa are normal. 

signs arc also greatly modified according to the quantity of fluid in the 
rudimentary half of the genital canal. If the retention tumor is chiefly 
or entirely limited to the uterine cornu, the sound half is merely crowded 
over to the other side, where it may be demonstrated by palpation or 
with the sound; if the cervix also is involved, the vaginal vault on the 
corresponding side is crowded downward, the septum in the cervix is 
pushed far down into the lumen, and the canal narrowed to a cleft; 
finally, if the occlusion is situated low down, and the vagina is also 
distended, the fluctuating tumor is found below, forcing the septum 
far downward into the lumen of the vagina, while above is found the 
dilated uterus (Fig. 329). In the last-mentioned cases we find a fluc- 
tuating tumor broadly attached to the entire width of the genital tube. 
The symptomatology is so important in these tumors that a 
definite diagnosis cannot be arrived at without giving it due consider- 
ation. The occurrence of severe dysmenorrheic pain without disturbance 



556 GYNECOLOGICAL DIAGNOSIS 

of menstruation, and a gradual increase of the symptoms associated 
with slow growth of the tumor, which may take place at each menstrua- 
tion, are characteristic; the interval between menstruation is usually 
quite free from pain. This regularity and intensity of the symptoms, 
however, presupposes normal functional activity of the atresic cornu; 
but very often the cornu is undeveloped, and menstruation is irregular 
and scanty. In such cases the coincidence of the pain with the men- 
struation is not so well marked, and the growth is exceedingly slow. 
Finally, if only mucus and pus accumulate in the tumor, the menstrual 
symptoms are entirely absent, although slow growth of the tumor goes 
on hand in hand with an increase of the pain. 

The differential diagnosis between hematometra and hydrometra 
is based on this symptom alone; while pyometra may be recognized 
by the presence of fever, the leukocytosis which often accompanies it, 
and the associated inflammation. 



SPECIAL DIAGNOSIS 557 



Diagnosis of Diseases of the Urinary Apparatus. 

Physiology. In order to understand the different disturbances 
of urination which form the starting point for the diagnosis of these 
conditions, I shall explain the physiology of urinary secretion. 

The urine which escapes from the renal pyramids collects in the 
pelvis and flows into the ureter. As soon as the urine enters these 
canals, the muscularis contracts reflexly and the urine is propelled by 
a succession of wavy contractions into the bladder, which it enters 
rhythmically at intervals ranging from a few seconds to one or two 
minutes. So long as the bladder is empty, the upper wall closes down 
over the lower like an inverted dish. The first urine collects in the 
lateral pouches and gradually separates the upper from the lower wall; 
certain divisions are thus formed by the adhering bladder-wall, until 
gradually the roof and the floor are completely separated. Until the 
bladder is distended by a large ciuantity of fluid it retains its flat and 
relaxed shape. Continence of the bladder is effected by means 
of the small muscles of the sphincter internus, which surrounds the 
neck of the bladder and produces a permanent, elastic, tonic closure. 
In addition the posterior half of the urethra is surrounded by trans- 
versely striated muscle, which is under control of the will, and is called 
into action only when the closure of the bladder is to be reinforced 
actively. When the bladder is filled to a certain point, the fact is con- 
veyed to the individual's consciousness through sensory fibres. A 
distinction is to be made between the sensation of a full bladder, 
due to distention of the viscus and felt as a full pressure in the lower 
abdomen, and true desire to urinate, which always originates in the 
neck of the bladder. As the distention continues, the region of the 
posterior fold of the internal orifice is obliterated or distended, and 
the urine enters the neck of the bladder, producing the desire to 
urinate. The sensation is probably produced directly by contraction 
of the striated muscle surrounding the urethra. Under pathologic 
conditions the sensation is frequently exaggerated, until it becomes 
a genuine pain. During evacuation of the urine the muscle 
is allowed to relax, either voluntarily or reflexly, thus opening the 
urethra. The urine then escapes from the bladder merely under the 
influence of intra-abdominal pressure. The mechanism of urination 
may be compared to the escape of the contents of a pot after a stopper 
in the bottom of it has been removed; just as the fluid escapes under 
the influence of air pressure after an opening has been provided, so the 



558 GYNECOLOGICAL DIAGNOSIS 

urine escapes from the bladder after the closure has been relaxed. 
Certain differences in urination, such as the force of the stream, depend 
on the degree of intra-abdominal pressure; spontaneous urination can 
take place only while the intra-abdominal pressure is positive. The 
acclerator urinse takes no part in urination; it merely renders the wall 
of the bladder elastic so that it may accommodate itself to its contents; 
possibly it may be responsible for the expulsion of the last few drops of 
urine. As the urine escapes, the bladder, becomes smaller and the intra- 
abdominal pressure forces the upper wall down on the lower, beginning 
in the median line. Concentric cozitraction of the bladder does not occur, 
and some urine usually remains in the lateral pouches. 

The diseases of the urinary apparatus that interest the gynecolo- 
gists are subdivided according to the individual organs into diseases 
of the urethra, bladder, ureter and kidneys. 

Diseases of the Urethra. 

The diagnosis of urethral diseases necessitates a number of methods 
of examination which differ from those ordinarily employed in gyne- 
cology and therefore require a separate description. 

Methods of Examination. Inspection. The patient is 

placed on the operating chair and the following points are noted: the 

position and size of the external urethral orifice; color and 

Methods of ^ 

Examination. degree of swelliug of the urethral mucous membrane; the 
swelling of the fold surrounding the urinary meatus; the 

urethral secretion; the presence of macules or reddening of the vestibular 

mucous membrane around the urethral orifice; and the presence of 

tumors at the urethral orifice. 

Palpation. The degree of swelling and sensitiveness of the 

urethra may be determined by introducing the finger into the vagina, 

and larger tumors along the canal may be detected in this way. Palpa- 
tion of the inner surface of the urethra is rarely neces- 
sary and is employed only if the results of sounding and 

endoscopy are unsatisfactory. It is not altogether without danger 

because it recjuires dilatation of the urethra. 

With palpation is combined the demonstration of a urethral 

secretion by milking the urethra from behind forward with the 

finger introduced into the vagina, the external orifice having previously 
been cleansed of any vaginal secretion that may adhere to it. 

Demonstration . . 

of Urethral Tlic quantity and nature of the secretion are determined 

and a smear is made for the purpose of looking for gonococci. 
Unless the secretion is very abundant, nothing will be obtained imme- 
diately after a urination; hence the examination should be made a few 
hours later, or, if there is very little secretion, early in the morning 
before the urine accumulated during the night has been discharged. 



SPECIAL DIAGNOSIS 



559 



y^mm m 



Examination with the sound is very important in the diagnosis of 
certain urethral diseases. A sound with a moderately thick head can be 
introduced without difficulty into a normal urethra if the 
mucous membrane is smooth and painless. The sound is 
employed chiefly for the purpose of detecting circumscribed areas of pain 
or irregularities, contractions of the lumen, or tumors in the urethra. 

Endoscopy is much less important in females than in males 
because the various urethral diseases can be recognized with certainty 
by palpation, by sounding, and by examining the secretions. It is 
therefore employed only in the presence of certain special indications. 
In chronic cases of urethritis with very little secretion and absence of 
swelling it is valuable for confirming the 
results of sounding, because it permits 
inspection of circumscribed changes in 
the urethral mucous membrane. It is 
also necessary in cases of hemorrhage 
from the urethra when urination is 
associated with severe pain that cannot 
be explained by recent inflammation. 
In cases of this kind one is prepared to 
find polyps, tumors, or foreign bodies 
in the urethra, and quite frequently such 
conditions must be differentiated from 
purely nervous states. Casper's endo- 
scope is the best instrument for endos- 
copy of the female urethra. 




Fig. 330.- 



Casper's Endoscope fob the 
Female Urethra. 



The upper extremity of Casper's endoscope 
is provided with a handle containing a large incan- 
descent lamp, which by means of lenses and prisms 
projects the light into the tube at a right angle. 

The observer looks into the tube directly above the prism, and is enabled to study 
the changes in the urethral mucous membrane under full illumination (see Fig. 330). 

For the successful performance of endoscopy the urethral orifice 
must be wide enough to admit a tube about 7 mm. thick; if not, it must 
be dilated with blunt dilators. The introduction of the tube from before 
backward is painful, but has the great advantage over examining from 
behind forward that the observer is not constantly disturbed by the 
fiow of urine from the bladder. If the urethra is too sensitive, one to 
two grams of a 10 per cent, solution of cocain is injected five minutes 
before the tube is introduced. If the examination is made from behind 
forward, the bladder must first be completely emptied, and even then 
the urethra as well as the tube has to be constantly sponged in order to 
keep them dry. The normal urethra appears in the tube as a cleft, which 



560 GYNECOLOGICAL DIAGNOSIS 

represents the lumen surrounded by the radiating folds of the mucous 
membrane. The mucosa is reddish and, in the posterior segments, 
sometimes purplish because of the many veins. The lacunae in the 
mucous membrane are recognized by their elevated border. Littre's 
glands cannot usually be seen distinctly. As the end of the tube glides 
through the internal orifice into the bladder, the much paler vesical 
mucous membrane appears in the opening, and urine begins to flow. 

Operative opening of the urethra, by means of a 

Operative ^ .,,... • i i i 

Opening of lateral and bilateral incision carried backward about one 

to one and one-half centimeters, is employed only after 
all other means have failed, as, for example, in cases of circumscribed 
tumors, especially when immediate removal is contemplated. 

Examination of the urine is of no special importance in 
the diagnosis of urethral diseases. While it is true that abnormal 
constituents, such as pus, blood, or particles of tumors, may be mixed 
Examination of with the uriuc, they are much more easily recognized by 
the Urine. exprcssiug them directly from the urethra. The main 

object in examining the urine in urethritis is to determine whether the 
bladder is healthy. For this purpose the urine must be obtained before 
it has been polluted by abnormal constituents from the urethra (catheter 
specimen); but in acute, and especially in infectious diseases of the 
urethra, catheterization is always attended by the dangers of infect- 
ing the bladder and is therefore contraindicated. In such cases 
Thompson's method of collecting the urine in two 

Thompson's . , 

Two Glass separate glasses must be substituted. The patient first 

Method. nil •! • 1 • f • 

flushes the urethra with a certain quantity oi urine and, 
after the vagina has been closed ofT with a tampon, the remainder is 
discharged into a separate glass and used for the examination. 

Urethritis. Urethritis is the most important of urethral diseases. 
In the acute stage its recognition is easy; in chronic cases and in the 
presence of sequelae it may be exceedingly difficult. In very acute inflam- 
mations the tissues around the external orifice are swollen and 

Urethritis. .... 

edematous. The urethral mucous membrane is intensely 
reddened in chronic forms, particularly in gonorrhea; the mucous 
membrane surrounds the urethral orifice, is reddened and macular, 
and sometimes the orifice is surrounded by condylomata acuminata. 
In recent cases the infiltrated urethra can be felt through the vagina 
as a thick, cylindrical, painful cord, which in a slighter degree may even 
be recognized in chronic cases. The presence of a secretion is the 
most important diagnostic point. The normal urethra is perfectly dry, 
and if fluid can be expressed, it indicates some alteration of the mucous 
membrane. In very recent cases pure yellow pus can be expressed in 
thick drops; after one or two weeks the flow of pus ceases and the 



SPECIAL DIAGNOSIS 561 

secretion becomes whitish. In this form, consisting principally of 
desquamated epithelium, it may persist for months or years and is one 
of the surest signs of chronic urethritis. The last stage of the secretion, 
which may continue for a long time, consists in a moderate degree of 
epithelial desquamation; finally, the secretion may cease altogether, 
leaving merely an irritative condition of the urethra which causes con- 
siderable discomfort during micturition. In the diagnosis of these cases, 
in which the patient complains of tickling and burning, prickling and 
itching, a "funnj^" feeling after urination, associated with a moderate 
degree of strangury, the sound is the most useful instrument. The 
slightest touch, particularly in the posterior urethra, produces pain 
and the same sensations as are felt during urination; sometimes irregu- 
larities are felt which are particularly sensitive to pressure. The loca- 
tion of these painful sensations can be detected with a fair degree of 
certainty and differentiated from vesical irritation by means of the 
sound. There is rarely any occasion to resort to endoscopy after using 
the sound, except possibly in cases of persistent urethral symptoms in 
which neither the examination of the secretion nor sounding yields any 
positive result. Personally, I have never felt the necessity of resorting 
to the endoscope in these cases, and therefore am unable to describe 
the pictures seen from my own experience. I shall accordingly follow 
Janowski, who describes a chronic circumscribed form. In the first 
place, the wall of the urethra is diffusely infiltrated and exhibits rough 
unyielding folds; in some places dense infiltrations are detected, which 
form heavy, yellowish-red folds on the surface of the mucous membrane, 
projecting into the tube. In the areas in process of healing the epithe- 
lium appears gray or the color of mother of pearl; strictures are rare. 
In the circumscribed form, infiltration is seen around the lacunae and 
Littre's glands; the epithelium is slightly gray and extremely vulner- 
able at the surface. As healing takes place the entire infiltrated zone 
is covered with delicate, distinctly retiform strands of cicatricial tissue, 
which gradually flatten out and become white; this is often attended 
with moderate constriction. 

Tumors of the Urethra. I shall use the word "tumor" to describe 
any circumscribed swelling of the urethral mucous membrane, whether 
it projects from the external urethral orifice or lies within the 
lumen of the urethra. The only conditions that possess Tumors of 

practical importance are polyps of the urethral mucous the urethra, 
membrane, condylomata acuminata, mucous polyps (caruncles), and 
carcinoma of the urethra. The diagnosis of these tumors is easy when 
they are situated at the edge of the orifice, or within it, and project 
from the lumen of the urethra at least far enough to allow the apex of 
the tumor to be seen. Under these circumstances they may be brought 
36 



562 GYNECOLOGICAL DIAGNOSIS 

into view a little better by pushing them forward with the finger through 
the vagina, or having the patient bear down. It is always desirable to 
see the greater portion of the tumor, particularly its point of insertion. 
The diagnosis is much more difficult if the tumors are situated so far 
within the urethra that they cannot be seen. In these cases the presence 
of a tumor (or of a foreign body) is suggested by the severe irritation 
that attends urination. Cramp-like pains radiating into the vulva, 
the anus, and often into both thighs; cramps in the floor of the pelvis, 
with violent tenesmus of the sphincter ani ; and hemorrhage from the 
urethra may also be present. The actual presence of a tumor is demon- 
strated with the sound or the endoscope. In making the differential 
diagnosis of the above-named conditions, we must determine by means 
of the sound or the catheter their relation to the orifice, and the presence 
of the urethral lumen in or alongside of the tumor. 

Prolapse of the urethral mucous membrane always causes 
alteration of the lumen. In circular prolapse the lumen is seen at the 
centre of the tumor; in partial prolapse of one wall the lumen is cres- 
centic and crowded over to the other side. Another sign 
th™ Urethral of prolapse is the ability to replace the relaxed mucosa 
MembTane. ^^^^^ rcstorc the caual, while at the same time the absence 

of circumscribed thickening in the wall is determined by 
simultaneous palpation through the vagina. The prolapsed mucous 
membrane presents every shade of red and, if gangrene is present, which 
is frequently the case, its color is a dirty brownish-red. 

Condylomata acuminata are recognized by their rough, 
papillary surface and pale red color; they are painless to the touch. 
Condylomata usually multiple, especially at the vulva, and associated 
Acuminata. with slgus of Catarrh. Sometimes they coalesce to form 

cauliflower-like growths around the urinary meatus. 

Caruncle or mucous polyp (vascular polyp) is almost always 

solitary and situated at the edge of the external urethral orifice. The 

surface is covered with smooth mucous membrane with 

Caruncle. . . , . , . , , 

an indented, pectinate border; the color is bright red 
and the tumors are exceedingly painful, both spontaneously and on 
contact, and occasionally produce cramps and vaginismus. 

Primary carcinoma situated at the external urethral orifice 
is rare; it resembles cancer of the vulva and is characterized chiefly 
by the infiltration at the base and the friable nature of the surface. 

Periurethral carcinoma is more common. Beginning 

Carcinoma. . , . , . ,,.„,. , 

m the urethra itself, it produces marked infiltration and 
a cartilaginous elastic swelling of the urethral fold; this is very char- 
acteristic and easily distinguished from inflammatory swelling, which 
is much softer. 



SPECIAL DIAGNOSIS 563 

Sarcoma is exceedingly rare. It begins in the deeper layers, 
causes bulging of the mucous membrane and dilatation of the urethral 
orifice, from which the tumor may project. 

Circumscribed tumors of the wall developing within the ure- 
thra may be sarcomata, fibromata, or mucous polyps; not infrequently 
tliey can be felt directly with the sound. Endoscopy of the urethra 
is of great importance in these cases. Ebermann has described the 
endoscopic findings with small tumors in the urethra. At the point of 
attachment the normal longitudinal folds disappear and, if the urethra 
is greatl}^ distended, those in the entire neighborhood also. The surface 
of a polyp appears smooth and intensely red, while papillomata have 
an uneven surface and in some places throw a circular shadow. Forced 
dilatation and digital exploration of the urethra is a method that is much 
more severe than endoscopy. If a positive diagnosis cannot be made 
by the methods so far described and a tumor is suspected, it is better to 
divdde the urethra on both sides instead of resorting to forced dilatation, 
and in case the diagnosis is confirmed, to remove the tumor at once. 

Tumors of the bladder, as well as urethral tumors, may grow into 
the urethra and force their way out from the external orifice. 

Calculi and foreign bodies are easily recognized with the 
sound or with the endoscope. 

Diseases of the Bladder. 

From the standpoint of the practitioner it is more advisable to begin 
with certain symptoms for which his advice is sought, and look for their 
causes, before discussing the diagnosis of the individual diseases of the 
bladder. A systematic description would be of no value for diagnostic 
purposes. Most patients come to the physician on account of symptoms 
occurring during urination — usually increased and painful micturition, 
or pain during the act (tenesmus vesicae, dysuria); rarely on 
account of incontinence of urine, or difficult or impossible urination 
(ischuria). In rare cases the patient seeks advice solely because she 
has noticed changes in the urine (hematuria). It then becomes the 
physician's duty to investigate the cause of these symptoms and make 
his diagnosis of the disease. Along this path I propose to guide him. 

Diagnosis of the Causes of Tenesmus Vesicae (Dysuria). 

Definition. Before discussing the diagnosis of this exceedingly 
common complaint, it is necessary to define the term "tenesmus vesicae." 
The frequent desire to urinate is not in itself pathologic; 
for, while it is true that a healthy woman does not urinate 
oftener than four or five times a day, and not at all at night, habit, 
the quantity of fluid ingested, and emotional excitement frequently 



,564 GYNE(()l,(){;i( Al- DIAC.NOSTS 

cause iucreascil niicluritiim under otherwise normal conditions. Tlu>se 
conditions, howex-er, 1 sliall omit altogctlier, and eonline niysell" to that 
form of dysuria whicdi is so intense and so paiid'ul as to bring the patient 
to the physician; or at h'ast forms the most pi'ominent symptom of lier 
disease. First of all, we nuisl make sure that the urination actually 
is abutu-mally freciuent, as the patient's ideas (Ui this suhiect are often 
V(M-y eurii)us. Nocturnal micturition, howe\-er, is alwaj's to be regartled 
as abnornuil. Next, we nuisl dt'terminc> that the desire to urinate 
really doc"s occur lu-iMu.aturely, i.e., when the bhuldtu' contains but a 
small tpiantity of ui'ine, a.nd that the fi'et|uent nru'turilioi^ is not also 
associalcnl with the evacuatiim of a large iimintity of urine, as, for 
example, in diabc^tes and interstitial nephritis. Micturition is to be 
rt'garded as pathologic when the desire- to urinate is excitinl by suuill 
(luantilies of urin(\ when it cannot be suppressed, and when it is attended 
by i^ain. This form oi pathologic micturition occurs in diseases of the 
nrethi-.n; in disivises o'i the bladder: in diseases near tlu- bladder, espe- 
cially oi the intei-nal genitali;\ ; and, iinally , as ;i purely ner\'ous syniptiuu. 
An\ong all these, diseasivs of the urinary organs are the most important. 

In searidiing for the canst- of dysuria, it is best to begin by i-xauiin- 
ing the ni'cthra. (For the methods and lindings, set- p.ages 558 to 5()o). 

If the causi- o( dysuria is not found in sonu- ui'cthi'al condition, 
we turn to the bladder, and begin with (,>x;iminal ion of the urine. 
t M' all the methods of examination uranalysis is tlu- least 
Kxamiiuuiou troublesome to the patient, requires the least technical 
skill, and in the majority oi cases tin- data obtained are 
entirely adequate for ;i diagnosis. In tlie main it consists in recognizing 
diseases o'i the bk-ulder by the presiMua- o( abiunanal constit luuits that 
are mixed with the ui'ine. or tduinges in the urine whicli haw- taken 
[dace in the l>ladder. The ui'iui- must be tduained free frcuu admixtiu'e. 
Avith nothing derived from other organs. .Vs in wonu-n it is very ditlicult 
to aNoiil imllution with \aginal secretion, the uriut- shtuild always be 
obtained b}' eallieter. 1 n recent gonorrheal ui'i-thritis, oi' if catheteriza- 
[\on is inqu^ssible for other reasons, the two-glass method must be em- 
ployed. In using a glass the bladder shotdd be complelidy i-mpticd and 
special attentiiMi nuisi be paid to the last o( the urine in which seilimeut 
and blood usual!}' collect. To determine whether a sediment is present, 
it is not eninigh to exan\ine the urine in the clnnnber, or even in a large 
urine glass: nor is the "little bottle of urine" that the women usually 
bring along with them adapted for an accurate examination. The 
urine should be collected in a thin, high gkuss i-eceptacle with a base, 
of a capacity of SO to lt1l) grams: lu- rcciMNcd directly luio test- 
tubes, in which, when held up to the light, the most minute sedimenl 
can be st-en with the unaided e\'e in the narrow ctdumn of urine. 



SPECIAL DIAGNOSIS rAi5 

If {he uriiu' in ;i tliin glass appears [x'rfcctly clear, vesical disease 
can be excluded with a vt-ry griwt degrc^e of probability; but if the 
urine contains a sediment, examination of the latter affords a very 
convenient method of diagnosis. Simple- inspcM'lion is rarely enough. 
The coars(\ pink sediment whicdi is pr(H'ipitat(Ml from high!}'' colored 
urines as they cool is of ccnirse at once recognized as urates; again, 
uniform turbidity in a recent urine, without tlu> formation of scMliment, 
indicates numerous bacteria; and a. uniform distribution of minute 
partich-s in suspension points to the ailmixturc- of organic elements, 
such as pus or epithelium; blood also can easily be recognized in the 
urine. In most cases, howexcr, chemical and sometimes microscopic 
examination (if tlie sedimcMit is neccvssary. 

Note. T sliall si'^''' I'ul.v l ho iin]i(nianl olciuoiilavy clu'iiiical ami inicroscopic urinary tests, 
and ivlVr I lie ivadiT fur I lie dot nils to I ho (oxl-iioolcs of I'osncr, Ulzmann, Z(il/,or and ( )lH'iiatnler. 

The chemical examination is b(>gun by warming part of 
the urinary sediment in a t(-st-tub(\ If the sedimcuit dissolves com- 
pletely it consists of sodium urate; if it does not dissolve, a few drops 
of acetic acid arc added, and if this cleai's up the sediment, chemical 

the urine contains phosi)hates; whelluM- thes(> nvc (>arthy E.xmnimuiou. 
phosiihates (phosphates of alkaline earth) or triple phosphatc-s (am- 
monium and magn(\sium i)hosphat(-s) is best determined by microscopic 
examination. If the scMliment is not. dissolved either by heat or by 
the addition of acetic acid, it probably consists of cellular const it u(mts — 
pus, epithelium, blood — or bacteria; if the sediment becomes nuire 
cloud}' on heating, there nux}' be an incrt-ased excretion id' i)hosphates, 
or the precii)itate may be albumin; the former are dissohcd by the 
atldition of a few drops of acetic acid, which does not aJl'ect albumin or 
even causes it to coagulate still more firmly. 

If chemical analysis shows the i)resence of an oi'ganic sedinunvt, 
it must be followed by micros co})ic (examination. If tlu> sedi- 
ment is abundant, a specimen may he obtained by allowing it to 
settle in a conical glass or in a filter pa.jxM-; if it is scanty Mi<.ms,-oi)ic 

it must be preci])italed in a centrifug(>. By means of the lixainniiu.on. 
centrifuge sediments can be recognized which would otherwise escape 
the examiner's notice; by its aid the diagnosis of diseases of the 
bladder has become very much more accurate, and the field of so- 
called nervous diseases of the bladder considerably narrowed. Normal 
urine contains no sediment, or at most a small (piantity of mucus with 
a few desquamated squamous epitludial cells. The first thing to look 
for under the microscope is pus, which is the most positive sign of 
inflammatory changes in any portion of the urinar}' apparatus, from 
the urethra to the parenchyma of the kidney. Pus is recognized without 



566 GYNECOLOGICAL DL4GNOSIS 

any difficulty. In the unstained preparation, the round, sharply out- 
lined pus cells may easily be distinguished under feeble illumination 
from all other admixtures of the urine. In alkaline urine they occasion- 
ally swell up and their contours become somewhat blurred, so that 
they are less distinct. Polynuclear pus cells are most easily recognized 
after the specimen has been stained with an anilin dye. The origin of 
the pus, whether from the bladder or from the urinary apparatus, cannot 
be determined with the microscope. Next in importance are the e pi- 
th elia} cells; they are rarely found in normal urine, but are more 
or less abundant in pathologic conditions; they occur in small aggre- 
gations, or even in large shreds; they are of the squamous variety, 
cuboidal, with prominent corners and retracted edges, and sometimes 
caudate. After prolonged exposure to the action of the urine, they 
swell up and their contours become indistinct. The origin of the cells 
cannot be determined by their microscopic appearance, but their presence 
in large numbers and coherent pieces is of pathologic significance. The 
presence of blood, whether in the form of well-preserved red blood 
cells, or washed out, degenerated cells, or merely pigment, must be noted; 
its origin, whether from the bladder or the kidney, cannot be decided 
by the microscope. Large quantities of mucus, either in the form 
of uniform glairy layers, or of individual mucous corpuscles, are often 
found suspended in the urine. The presence of microorganisms is 
very important from the etiologic standpoint; they may be demon- 
strated by the dry method, in the hanging drop, or by staining a speci- 
men with an anilin dye; for identifying the different varieties an oil 
immersion lens is required. In ordinary practice the most important 
bacteria are gonococci and tubercle bacilli. Amorphous and crys- 
t aline precipitates are also found, either with organic sediment 
or without it. Amorphous urates and needle- or rosette-shaped urate 
crystals and phosphates, thorn-apple crystals of ammonium urate, 
yellowish whetstone crystals of uric acid, the square envelope-shaped 
crystals of calcium oxalate, and the coffin-shaped crystals of ammonium 
and magnesium phosphate are the most common. 

The odor of the urine has only a very subordinate diagnostic 

significance. In infectious cystitis with ammoniacal decomposition 

the sharp, pungent odor of ammonia is noted; while in 

Odor. . .. ■lip 11-- 

chronic cystitis, particularly oi gonorrheal origin, the 
urine is generally not decomposed and odorless. If the bladder contains 
necrotic tumors, the urine has a fetid odor. 

The reaction of the urine becomes alkaline in cystitis with ammo- 
niacal decomposition, and occasionally also in disturbances of metabolism. 

Catarrh of the bladder is by far the most common cause of 
dysuria and can be diagnosticated by examination of the urine alone. 



SPECIAL DIAGNOSIS 567 

The urine contains catarrhal secretion, consisting chiefly of pus and 
bladder epithehum. The quantity of pus raa}^ be exceedingly variable. 
In acute forms it is often so abundant that it forms a heavy sediment; 
while in chronic, and especially gonorrheal cases, the quan- 



tity is often so small that it cannot be recognized as a Findm<rs m 



Urinary 

dings in 

Catarrh of 



sediment. If large quantities of pus are constantly found the Bfadde" 
in chronic cases of catarrh of the bladder, some other 
source must be suspected, such as the formation of diverticula, per- 
forating abscess, pyosalpinx, or suppuration of the kidney. The presence 
of pus is always one of the most important signs of catarrh of the bladder, 
but occasionall)' it may point to suppuration higher up. ^Yhether the 
pus is derived from the bladder or the kidney can be determined only 
wdth the aid of the cystoscope. Epithelial cells are found in addi- 
tion to pus in catarrh of the bladder in acute cases, otten in large coherent 
masses. In chronic catarrh, and sometimes after recovery from an 
acute condition, epithelial desquamation ma}^ continue for some time 
with moderate subjective symptoms. Whether the epithelial cells are 
derived exclusively from the bladder cannot be decided by the micro- 
scope. Blood is found only in acute vesical catarrh, intimately mixed 
with pus; protracted or repeated hemorrhages and large quantities of 
blood without pus always suggest some severe disease of the bladder 
or kidney. Mucus is usually present in catarrh of the bladder. With 
regard to microorganisms, a large number of bacteria in the 
urine usually indicates catarrh due to external (catheter) infection; 
in gonorrheal cystitis no bacteria, not even gonococci, are found as a 
rule. An alkaline or neutral reaction in connection with the presence 
of organisms, triple phosphates and pus, suggests vesical catarrh, par- 
ticularly the form which is apt to follow the use of a dirty catheter: 
in gonorrheal cystitis the reaction of the urine is usually normal, and 
in tuberculosis it is usually excessively acid. Ammoniacal odor of 
the urine occurs in cat-arrh with decomposition, but a normal odor 
does not exclude the presence of catarrh. 

Chemical and microscopic examination of the urine in most 
cases affords all the data necessary for a positive diagnosis of vesical 
catarrh; hence cj^stoscopy should not as a rule be employed on 
account of the danger of infection and the procedure is absolutely 
contraindicated in acute cases. 

But in protracted and severe catarrhs cystoscopy must be employed 
in order to search for the cause which produces and keeps up the catarrh, 
such as a foreign body or a calculus; whenever there is a suspicion of 
some specific infection, such as tuberculosis; or when with but slight 
urinary changes the subjective symptoms are intense, in order to 
discover unusual complications, such as ulcers. 



568 



GYNECOLOGICAL DIAGNOSIS 



The cystoscopic picture in cystitis is very complicated, being com- 
posed • of hyperemia, swelhng of the mucous membrane, ecchymoses, 
ulcerations, and the pathologic secretion of the diseased bladder wall. 

Hyperemia produces dilatation of the vessels, both of the medium 
sized and smaller veins and of the capillaries. The number of blood- 
vessels is greater than normal, and they appear either as ramifying, 




3 4 

Fig. 331- — Cystoscopic Pictures in Vesical Catarrh. 1. Increase of the vascular trunks in chronic 
cystitis. 2. Marbling of the mucous membrane in capillary hyperemia with irregular distribution. 3. Swell- 
ing of the mucous membrane, with ulcers and hemorrhages in chronic cystitis. 4. Flat ulcerations covered 
with mucus and incrustations. (After Zangemeister.) 

vascular trees or as a network. The intervening portions of the mucous 
membrane may retain their normal yellowish-white color if the capil- 
laries are not involved (Fig. SSIJ; if the capillaries are also engorged, 
the mucous membrane presents a diffuse redness, ranging from pale 
red to scarlet or brownish-red; the variations of color give the mucous 
membrane a marbled appearance (Fig. SSlj). Diffuse redness may 
completely obscure the larger ectatic blood-vessels. (It should be 
noted that the degree of vascular injection can be correctly determined 
only if the prism is clean and the light very intense.) Hyperemia 



SPECIAL DIAGNOSIS 



569 



produces a peculiar glistening appearance of the mucous membrane, 
which is particularly well seen in recent conditions; later the super- 
ficial layer of epithelium desquamates and the mucous membrane 
appears velvety and lustreless. 

Swelling of the mucous membrane is almost always 
present. In recent severe catarrh of the bladder the mucous membrane 
is edematous and easily thrown into folds; in chronic conditions 
signs of hypertroplw are more prominent. The membrane is greatly 
thickened and forms large folds; even the larger vessels can barely 
be seen underneath (Fig. 33 IJ. The entire bladder wall, or only 
circumscribed portions, may be swollen; most frequently the floor 
and the region of the ureteral orifices share in the hypertrophy. 





Fig. 332. — Cystoscopic Picture in 
Cystitis Trigoni. The mucous mem- 
brane shows erosions (red) and scaly 
shreds floating in the irrigation water 
with a precipitate of mucus (white). 
Tlie neck of the bladder is swollen and 
covered with adherent mucus (modified 
after Zangemeister). 



Fig. 333. — Tubercles on the Vesi- 
cal Mucous Membrane, usually situated 
at the bifurcation of the blood-vessels 
(modified after Zangemeister). 



Ecchymoses are frequently associated with severe hyperemia 
and appear as small hemorrhagic points, usually situated along the top 
of the folds (Fig. -SSlg). The mucous membrane bleeds at the slightest 
touch with the cystoscope. 

Ulcerations are quite frequent, particularly on the floor of the 
bladder, and are recognized as differences in level, often with sharp 
borders and covered with secretions or whitish masses which represent 
incrustations of precipitated salts (Fig. 331 J. 

The secretion is seen adherent to the wall in large or small 
shreds (Fig. 332), or it covers the wall in the form of small white dots, 
or floats in the irrigation water after separating from the mucous 
membrane. It may be so abundant that cystoscopy is practically 
impossible in spite of careful irrigation of the bladder; while in certain 
forms of catarrh it is so scanty as to be barely seen. 



570 GYNECOLOGICAL DIAGNOSIS 

It is important to determine by means of the cystoscope the variety 
of vesical catarrh present. Acute cystitis is characterized by 
marked vascular injection and an increase in the number of visible blood- 
vessels, or by diffuse hyperemia. The mucous membrane is shiny, 
somewhat edematous, and presents erosions and ulcerations with hemor- 
rhages in and on the free mucous membrane. The secretion is abundant. 

In chronic cystitis diffuse hyperemia is more rare; the mucous 
membrane is usually pale pink in color or even grayish-white, lustreless, 
and so thick that the vessels cannot be seen through it; swelling 
is very' marked and leads to the production of folds. Hemorrhages 
are much more rare. 

The cystoscopic picture of gonorrheal cystitis is not char- 
acteristic. The above-described changes characteristic of acute and 
chronic processes are seen. The localization of the lesions at the neck 
of the bladder is characteristic, and in the form of chronic cystitis 
of the neck of the bladder, it frequently represents the last and only 
sign of former infection of the bladder wall. The trigonum in these 
cases is greatly injected, and the mucous membrane is swollen and 
covered with mucus. Punctate hemorrhages are often scattered over 
the mucous membrane. 

Tuberculous cystitis is a cystitis accompanied by tuber- 
culous infection of the bladder; but the cystitis is by no means a con- 
stant phenomenon, and tuberculosis of the bladder without cystitis is 
very frequently observed. The associated cystitis is not characteristic 
and presents the same pictures as those described above; on the other 
hand, tuberculosis of the bladder often produces such definite changes 
that the diagnosis can be made by the cystoscopic picture alone. This 
consists in tubercles, which appear as grayish-white or reddish 
nodules as large as a hemp-seed and often surrounded by a red areola; 
they are found frequently at the bifurcation of the blood-vessels, and 
particularly at the trigonum and fundus and, in descending renal tuber- 
culosis, around the ureteral orifices. As the tubercles degenerate, 
ulcerations are formed which are not characteristic and can be recog- 
nized as tuberculous only by their immediate proximity to tuberculous 
nodules. When a descending renal tuberculosis reaches the bladder, 
the orifice of the diseased ureter appears rough and ragged, with irreg- 
ular, notched edges surrounded by recent tubercles. (In every case of 
tuberculosis of the bladder the kidneys must also be examined for 
tuberculosis, see page 591.) 

A rare cause of frequent micturition, usually with pain, is found 
in contraction of the bladder (Schrumpfblase), or hypertrophy of 
the bladder wall with contraction of the lumen, which usually fol- 
lows chronic catarrh. The desire to urinate is increased in inverse 



SPECIAL DIAGNOSIS 571 

proportion to the capacity of the bladder. The diagnosis of this 
condition is made by filHng the bladder; if the desire to urinate occurs 
regularly when the organ is onl}^ moderately distended, say with 80 to 
100 c.c. of fluid, and the urine escapes along the side of contracted 

the catheter, the capacity of the bladder is less than normal. Bladder. 

Acute catarrh and severe irritation of the bladder must be excluded; 
sometimes the thickened wall of the bladder can be directly felt. 

Other causes of painful tenesmus are tumors, calculi, and foreign 
bodies in the bladder; but as they also produce other symptoms and 
require a different diagnostic method, they are not included in the 
present analytical diagnosis and will be discussed in a separate section 
at the end of this chapter. 

There is no doubt that the cause of dysuria is most frequently 
found in diseases of the urinary apparatus itself, and since the employ- 
ment of the more delicate methods of examination, particularly the 
centrifuge and the cystoscope, the number of cases in 
which the bladder and urethra are found entirely normal ^Dise^eso" 
in the presence of well-marked dysuria has become greatly ^^^or'^.Tans' 

reduced; nevertheless some cases remain in which the cause 
of the dysuria must be sought elsewhere, chiefly in certain diseases of 
the genital organs. The manner in which the symptom is produced 
in these diseases is variable. Some lead to diminution in the size 
of the true pelvis and pressure on the bladder, or displacement of the 
bladder with distention of the sensitive floor of the organ. Such condi- 
tions are pregnancy, myomata, retroflexion of the uterus, especially of 
the gravid uterus, tumors of the adnexa, anteversion and anteflexion, 
anteposition, retro-uterine hematocele, and abscess in Douglas' space. 
Another class of diseases produce frequent micturition reflexly, par- 
ticularly vulvitis, colpitis and other diseases of the mucous membranes. 
Inflammations in the neighborhood of the bladder, such as metritis, 
perimetritis and parametritis, exudates and pyosalpinx produce uri- 
nary symptoms because the bladder takes part in the hyperemia 
of the pelvic organs, or because the sensitiveness of the vesical 
mucous membrane is increased, although no local changes are present. 
Any one of these conditions may be the cause of frequent micturi- 
tion, but only if the urinary organs themselves are found to be 
health3^ Dysuria due to disease of the bladder and urethra is attended 
by pain, which is usually absent in genital diseases, with the exception 
of vulvitis, when the inflamed areas are irritated by the urine, and 
perimetritis, in which the serous covering of the bladder is involved 
in the inflammation. 

If careful examination of all the adjacent structures fails to reveal 
anything abnormal, the tenesmus must be explained as a local neurosis. 



572 GYNECOLOGICAL DIAGNOSIS 

Cases of this kind undoubtedly occur, although since the introduction 
of cystoscopy the number of cases of so-called irritable bladder has 
been very much reduced, and the diagnosis is nowadays admissible 
Vesical only when neither the bladder nor the genitalia can be 

Neurosis. regarded as the cause of the tenesmus. Medical treatment 

is required only if the constant desire to urinate becomes troublesome 
or interferes with the patient's occupation or general health. As a rule 
the patients are hypersensitive, hysterical individuals. The diagnosis 
is made entirely by exclusion. 

Diagnosis of the Causes of Incontinence. 

Definition. Incontinence, or the involuntary evacuation of 
urine, is a condition in which there is a constant or periodic discharge 
of urine not accompanied by the sensation of a physiologic desire to 
urinate. A very different condition is meant by the patient when she 
says that she cannot hold her urine, and consists in an intense tenesmus 
with a constant dribbling of urine. The latter form of involuntary 
urination is due merely to the fact that the patient is unable to suppress 
the desire to urinate long enough to reach the closet. The changes to 
which it is due are of an entirely different nature and belong to dysuria. 
Before making a diagnosis of incontinence it is therefore wise to exclude 
this condition by inquiring carefully into the history. 

The diagnosis of incontinence itself is easy. Eczema and 
furuncles are often seen in the neighborhood of the genitalia, there is 
a urinous odor, and a discharge of urine. There are, of course, differ- 
Diagnosis of euces, depending on the nature and intensity of the disease 
inccntmenee. -^^rhich causcs the iuvoluntary urination. In the severest 
cases the patients cannot hold a single drop, and the urine flows con- 
stantly wdiile they are standing up or lying down. In less severe cases 
there is complete continence in the horizontal position; or the woman 
is at least able to hold the urine for a long time, but loses it as soon as 
she stands up. In still milder cases continence is preserved in the erect 
posture, and the involuntary discharge occurs only after sudden exer- 
tion, after abdominal pressure — as during coughing or sneeezing — or 
during active exercise. 

The physician's most important duty is to discover the causes 
of the incontinence, which may reside in two entirely different 
conditions, either in fistula and injuries of the urinary 
apparatus, or in insufficiency of the closing apparatus of 
the bladder. 

The distinction between these two conditions, as well as the diag- 
nosis of incontinence itself, can usually be made in the following manner: 
The patient is placed on the examining chair, and the source of the 



SPECIAL DIAGNOSIS 573 

urine, whether in the urethra or in the vagina, is determined by inspec- 
tion. This is the most important point to settle; for if the urine flows 
from the vagina, there must be an abnormal communication between 
the urinary and the genital apparatus (fistula), while the discharge 
from the normal channel merel}^ indicates insufficiency of the sphincters 
which control the urethra. 

A fistula may be felt with the finger if it is situated in the vagina 
and has attained a certain size, and it may be possible to introduce the 
finger into the bladder and to feel defects in the vesicovaginal septum 
if they are large. If the fistulous opening is small or hidden Diagnosis 

among the folds of mucous membrane, it is more easily of Fistula. 

found with a Simon speculum. As soon as the entire anterior bladder 
wall is exposed in the speculum, the urine is seen to flow and collect in 
the speculum. By carefully noting the direction from which the urine 
appears to come, the small fistula is discovered and may be exposed by 
separating the mucous membrane with hooks and tenaculum, so as to 
bring the fistulous opening and the flow of urine into the field of vision. 
If there is any doubt whether the opening is really a fistula or the external 
OS, or only an apparent opening, a catheter may be introduced into the 
bladder and brought out again through the supposed fistula; or, if this 
fails, the catheter is allowed to remain in the bladder, and a sound intro- 
duced into the fistula, and the two brought into direct contact. If it 
is found impossible either to expose the fistula or to see the discharge of 
urine directly, the so-called milk test is employed. An irrigator 
is filled with about a litre of warm milk and the tube attached to a 
catheter. After the anterior vaginal wall and the external os have 
been exposed in a Simon speculum, the catheter is introduced into the 
bladder while the lower opening is held shut, the vagina is wiped dry, 
and the milk allowed to flow. If the fistula is large, the milk appears 
at once; if the fistula is small, the first portion of the milk introduced 
often fills the bladder and, as the speculum is displaced or the folds of 
mucous membrane are separated with hooks, the milk suddenly makes 
its appearance. Sometimes, when the bladder is very much distended, 
the milk flows out again through the urethra and runs into the vagina, 
and under these circumstances it may appear to come from a fistu- 
lous opening, whereas the only condition present is incontinence of 
the urethra. The milk test is a very reliable method of diagnosti- 
cating incontinence, and at the same time of detecting a fistula and 
determining its nature. 

If the presence of an abnormal communication has thus been recog- 
nized, it remains to be determined where the fistula begins in the urinary 
apparatus and in what portion of the genital apparatus it terminates. A 
fistula may begin in the bladder or ureter and end in the vagina or uterus. 



574 GYNECOLOGICAL DIAGNOSIS 

Occasionally urethrovaginal fistulte are also seen; but they 
have no special significance because a small communication between 
the anterior half of the urethra and the vagina merely causes a slight 
change in the stream during urination and does not produce incon- 
tinence; a fistula in the posterior half, on the other hand, usually extends 
to the bladder; or, since it is always associated with the destruction 
of the closing apparatus of the bladder, produces the same kind of 
incontinence as a vesical fistula. 

The seat of the fistula ma}^ in itself decide whether it is a vesical 
or a ureteral fistula. The latter are usually situated to one side 
in the vaginal vault and rarely open into the cervix; while vesical 
fistula; are almost always situated in the anterior wall. A positive 
distinction can be made by means of the milk test. In vesical fistula 




Fig. 334. — Cystoscopic Picture in a Case of Traumatic Fistula in the Trigonum. The posterior portion 
of the fistula is healed. (Modified after Zangemeister.) 

the milk always returns; although, if the opening is small, it may be 

necessary to separate the edges with hooks. In ureteral fistula the 

injected milk does not return but fills the bladder itself, while clear urine 

often drips from the fistula at the same time. The character 

Vesical, or , , 

Ureteral of tlic fistula cau be determined m most cases by sounding. 

If a catheter is introduced into the bladder and the fistula 
sounded through the vagina, the two instruments touch one another; 
whereas in the case of a ureteral fistula a small sound passes backward 
and upward a considerable distance without touching the catheter in the 
bladder. The next step is to determine whether the vesical fistula opens 
into the vagina (vesicovaginal fistula), or into the cervical canal 
with or without loss of part of the anterior lip (vesi co-uterine fis- 
tula). In simple cases the opening of the fistula underneath the vaginal 
portion in the anterior vaginal wall can be discovered with the finger; or 
on inspection with a speculum the entire vaginal wall ma}'' be found entirely 
normal, and the urine seen to escape from the external os. In more 
difficult cases the point must be decided by the milk test. The cervix 



SPECIAL DIAGNOSIS 575 

is plugged with a firm tampon and the milk introduced into the bladder. 
If it returns, the fistula must open in the vagina; if not, the opening is 
in the cervix. It is difficult to see the fistula directly within the cervix 
if the latter is well formed and the external os is not much dilated. 
But if part of the anterior lip is destroyed, it is much easier to see the 
fistula and, if necessary, to introduce the sound. Incision of the cervix 
for diagnostic purposes is not necessary. In the case of ureteral fistula 
the exact seat of the opening is more difficult to determine because the 
milk test cannot be employed. If the opening is in the vaginal vault 
it can easily be seen and sounded (uretero vaginal fistula); 
but if the ureter opens into the cervix — u retero-uterine fistula — 
the diagnosis can only be made by positively excluding a vesico-uterine 
fistula; or, in other words, by repeatedly obtaining negative results 
with the milk test, when there is no doubt that the flow of urine is from 
the uterus. In cases of this kind, when it is important to demonstrate 
that the fluid coming from the uterus is urine, the secretion must be 
colored by injecting a solution of indigo carmine under the skin. After 
the diagnosis of fistula has been positively established, it may be neces- 
sary, if an operation is contemplated, to examine for cicatricial changes 
and adhesions in the edges of the fistula. 

Cystoscopy may afford information in regard to the existence, 
position, and occasionally also the cause of a vesical fistula; or, what 
is still more important, the topographical relations of the ureteral 
orifices to the edge of the fistula. For the diagnosis of 

Cystoscopy ia 

ureteral fistula cystoscopy is superior to all other methods. the Diagnosis 

..... , . , of Fistulae. 

Incontinence is an obstacle to its employment in the case 
of vesical fistula. As the bladder must contain at least from 100 to 
150 c.c. of fluid, cystoscopy is necessarily restricted to cases of small 
fistula^, or cases in which the patient can control the bladder sufficiently 
in the recumbent position. As a rule the fistula has to be closed tem- 
porarily by packing the vagina with a tampon or the colpeurynter, 
or by pinching the vaginal walls or the lips of the external os together 
over the fistula with forceps. — In cases of large fistulae cystoscopy is 
out of the question. 

A vesical fistula is recognized as a black hole in the bladder (owing 
to the absence of illumination) surrounded by smooth or thickened 
mucous membrane, usually exhibiting cystitic changes; ciuite often the 
fistula is continuous with a scar (Fig. 334). A careful search is necessary 
when the fistula is small. Occasionally it is completely hidden between 
the folds of mucous membrane and cannot be discovered at all. Under 
such circumstances cystoscopy may fail. 

Case 31. A woman with partial incontinence following the first delivery has a small 
vesicovaginal fistula distinctly visible in the vagiiia. Although the tip of a small sound could 



576 GYNECOLOGICAL DIAGNOSIS 

be introduced into the fistula, I was unable to find the opening in the bladder, even after a 
long search with the cystoscope; but finally discovered it hidden among the folds of the mucous 
membrane after I had marked the place by introducing a matclistick through the vagina. 

The ureteral orifice is seen at the edge of the fistula or at some 
distance from it. If it is hidden among the folds of mucous membrane 
it may be found more easily by means of chromocystoscopy; if both 
ureters are found to functionate normally, a ureteral fistula is excluded. 
Cystoscopy in the form of chromocystoscopy finds its greatest field of 
usefulness in the diagnosis of ureteral fistula. If the stream of 
urine is absent on one side, the presence of a (ureteral) fistula may be 
assumed when there is involuntary discharge of urine through the vagina, 
and vesical fistula has been positively excluded. In doubtful cases 
the diagnosis may be confirmed by introducing a ureteral catheter into 
the corresponding ureter; the catheter will not pass beyond the solu- 
tion of continuity in the ureter and, if it is allowed to remain in place, 
the absence of urinary secretion on that side can thus be demonstrated. 
The catheter must be introduced very carefully in order to avoid per- 
forating the scar tissue with the point. By carefully observing the ure- 
teral orifice in cases of ureteral fistula it is sometimes possible to find 
out whether the ureter is entirely divided or merely contains a lateral 
opening. In the former case the contraction-wave which descends 
along the ureter is interrupted at the point of division, and the con- 
tractions at the ureteral orifice are abolished — "the ureter lies dead." 
If the ureter is only partially opened, the contraction-wave still descends 
but the urine is not projected into the bladder, because it flows out 
through the fistula; in that case, contractions are seen at the ureteral 
orifice without the discharge of urine — "the ureter goes empty." In 
the following case cystoscopy stood me in very good stead : 

Case 32. During my service in Berlin I undertook a double oophorectomy. Two 
weeks later, after a fever of several days' duration, the laparotomy-scar reopened and dis- 
charged at first pus, and then a serous, turbid fluid with a urinous odor. Division of a urachus 
was excluded because the vertex of the bladder on cystoscopic examination was found to 
be normal. As the milk test was also negative, the possibility of a fistula from the ureter to 
the abdominal walls suggested itself. I made another cystoscopic examination and found 
that the function of the left ureter was normal, while on the right side there were contractions 
at the ureteral orifice without the discharge of urine (empty ureter). I accordingly diag- 
nosticated partial division of the right ureter and, to confirm the diagnosis, introduced 
ureteral catheters on both sides. On the left a normal quantity of urine was discharged, 
but not a drop on the right. 

The other cause of incontinence is insufficiency of the clos- 
ing apparatus of the urethra. This condition may be surmised 
if the patient complains merely of occasional dribbUng of urine, especi- 
ally during abdominal pressure (cough, etc.) or when the legs' are widely 
separated as in taking long strides, and the discharge of urine is not 



SPECIAL DIAGNOSIS 577 

constant. On examination the diagnosis is confirmed by seeing the 
flow of urine from the urethra. If the patient is made to cough and 
bear down, the urine usually begins to dribble or is projected in a stream. 
If this does not occur, the diagnosis of insufficiency of the closing 
apparatus is made by excluding the presence of a fistula with the milk 
test. The cause of the insufficiency is more difficult to discover. 
As a rule it is found in paresis or paralysis of the sphincter muscle, fol- 
lowing chronic vesical catarrh due to traumatism (parturition), or in 
nervous persons; quite often no cause for the paralysis can be dis- 
covered. In other cases there may be traumatic or ulcerative destruc- 
tion of the urethra. In traumatic conditions the edge of the scar is 
smooth; while ulcers, which are often syphilitic, are surrounded by 
extensive callous thickening and other ulcerations in the neighborhood. 
Ulcers in the anterior half of the urethra do not cause incontinence; 
but if the posterior half, or even the muscle bundle of the sphincter 
muscle is also involved, the urine cannot be controlled. From one- 
third to one-half of the posterior urethra is necessary for normal bladder 
control. Nocturnal enuresis belongs to this variety of incontinence 
and must also be ascribed to paresis of the closing apparatus. It may 
be easily recognized from the patient's statements. A rare cause of 
incontinence is found in congenital malformations, such as 
division (hypospadias or epispadias) and complete absence of the 
urethra, vesical fistula or urachus fistula. These conditions, so far as 
they are observed in the living subject at all, are usually discovered in 
earliest youth, or else the history clearly indicates their congenital 
origin. The diagnosis is easy and depends merely on a proper under- 
standing of the topography. On the other hand, conditions in which 
the ureteral orifices are abnormally placed, particularly in the vulva, 
are very difficult to recognize. 

Case .33. Anna G. states that she is supposed to have been unable to control her lu'ine 
since birth, but maintains that she is able to urinate in the normal manner. The uretlu-a 
is normal, the introitus partly closed by the hymen; to the right of the hymen is found the 
opening of a wide mucous canal which can be followed about 2 cm. with a sound and does 
not communicate with the urethra or vagina; sounds introduced into the tlu-ee canals at 
the same time do not come in contact with one another. There is involuntary but periodic 
discharge of the urine, which evidently comes from the abnormal canal on the right side. The 
milk test is negative; not a drop of milk returns either from the vagina or from the ui-etlira. 
The urine is clear; the capacity of the bladder is about 200 c.c. On cystoscopic examination 
a normal ureteral opening is found on the left side, with an intermittent flow of urine; while 
on the right no ureteral orifice can be seen. 

Diagnosis of the Causes of Ischuria. 

Definition. Ischuria signifies difficult urination, or inability 
to urinate. In mild cases the evacuation of urine is merely delayed 
and the act must be assisted by straining and bearing down; in other 

37 



578 GYNECOLOGICAL DIAGNOSIS 

cases the patient is able to urinate only in certain attitudes, or drop 
b}^ drop; in severe cases there is complete retention and the bladder 
becomes distended. The involuntary escape of urine from an excessively 
distended bladder is called paradoxical ischuria (incontinence 
with retention.) 

The diagnosis is based in the main on the above statements 
obtained from the patient, but the presence of an excessively distended 
bladder, especially with complete retention, is also confirmatory. The 
Diagnosis diaguosls is most hkely to be missed when there is dribbling 

of Ischuria. ^ of uHnc, becausc the fact that the urine escapes seems to 
exclude the possibility of ischuria. In doubtful cases the diagnosis 
is decided by the catheter. In a special form of ischuria the patient 
fails to empty her bladder completely and retains a certain amount of 
residual urine; cases of this kind are best explained by assuming 
insufficiency of the accelerator urinse. It is recognized by introducing 
the catheter after urination and drawing off the residual urine; the 
quantity of the latter will serve to indicate the degree of ischuria present. 

While the diagnosis of ischuria may in general be regarded as easy, 
considerable difficulties arise in discovering the causes of the condi- 
tion. Yet this question must be decided in every case, because ischuria 
is often a permanent trouble that disappears only with the 
removal of the cause. I shall subdivide ischuria into a 
mechanical form, in which the inability to evacuate the urine is due to 
a mechanical obstacle; and a functional form, which is due to a nervous 
disturbance of the mechanism of urination. 

The diagnosis of mechanical ischuria is made by finding a 
mechanical obstacle to the evacuation of urine. The mechanism may 
be intact or may also be involved. Diseases of the urethra, 
Mechanical such as stricturc, periurethral carcinoma and syphilitic 

isciiuna. scars, frequently produce difficulty in urination, but rarely 

complete ischuria. The diagnosis is readily made by introducing a 
catheter or a thin sound; but it must be remembered that it is possible 
to discharge the urine through a very much contracted canal. Condi- 
tions within the bladder are less frequent causes of ischuria in 
females; they consist in sudden closure of the internal urethral orifice 
by calculi, tumors, foreign bodies, or blood clots. Diseases of the 
genitalia are much more important in women and produce ischuria 
either by directly compressing the urethra against the symphysis, or 
by displacing and distorting the posterior urethra along with the floor 
of the bladder. In the latter form ischuria is one of the most important, 
as well as usually the first symptom of incarceration. Among the 
tumors that produce ischuria are submucous myomata that have been 
extruded into the vagina, large carcinomata of the vagina, hemato- 



SPECIAL DIAGNOSIS 579 

colpos, myomata and large carcinomata of the cervix, retroflexion of 
a gravid uterus in the third or fourth month, retro-uterine hematocele, 
large exudates in Douglas' space, retro-uterine ovarian tumors, and 
pelvic tumors. These conditions are as a rule easily recognized because 
the tumors are always large and fill the entire pelvis. The diagnosis 
of a mechanical cause of ischuria is often missed because no examina- 
tion is made, and the symptoms in women are attributed offhand to 
hysterical paralysis of the bladder. This is a grave error because the 
mechanical obstacle is not removed, and the constant catheterization, 
especially when performed by the patients themselves, may produce 
severe cystitis and pyelitis. In every case of ischuria a bimanual exami- 
nation must be made at once in order to search for the local cause. 

Ischuria is functional when it is due to a nervous disturbance 
of the mechanism of urination. In order to understand how this nervous 
influence may act it must be remembered that under normal conditions 
the impulse to urinate is conveyed along the sensory nerve Functional 

paths from the inner surface, and especially the neck of ischuna. 

the bladder. This is immediately followed by reflex relaxation of the 
sphincter muscle, after which the bladder is emptied by means of 
abdominal pressure, the accelerator urina? being emploj^ed, if at all, for 
evacuating the last remaining drops of urine. It is evident, therefore, 
that functional ischuria may be due to disturbances of reflex activity, 
or to the inability to allow abdominal pressure to act with sufficient 
force. Reflex disturbance may affect either the sensory path which 
conveys the impression of a full bladder to the central organ, or the 
centrifugal path which effects relaxation of the closing apparatus. 
These two processes cannot be considered separately, except when there 
is a disturbance of conduction in the peripheral nerves; in most of the 
cases the mechanism must be taken as a whole. 

The diagnosis of functional ischuria is made by excluding all 
possible mechanical causes; for if no obstacle to the evacuation of 
urine can be found anywhere, nothing is left but some disturbance in 
the nervous apparatus. The diagnosis is therefore in the main easy; 
but in the attempt to determine the nature of the functional disturbance 
and what particular portion of the nerves and nerve-centres concerned 
in the mechanism is affected — whether the disturbance is peripheral 
or central, whether it is based on organic changes in the nervous 
apparatus, or purely functional — great difficulties are encountered. 
Paralysis following a severe vesical catarrh and probably due to some 
alteration of the nerve fibres in the bladder wall must be regarded as 
peripheral. Ischuria due to changes in the central organs is, however, 
more freciuent. Organic disease of the spinal cord may destroy the 
reflex apparatus and interfere with active abdominal pressure; in acute 



580 GYNECOLOGICAL DL\GNOSIS 

febrile diseases with coma ischuria occurs because the desire to urinate 
is not perceived and the sphincter cannot be relaxed. Hysterical per- 
sons have ischuria because they lose control over the sphincter. Ischuria 
following operations on the vulva and vagina is due to disturbances 
of reflex action, and ischuria after laparotomy and during the puer- 
perium is often due to the inability of the patient to exert abdominal 
pressure in the horizontal position. Ischuria following operations in 
which the peritoneum has been stripped from a large portion of the 
bladder, is also explained by injury of the bladder nerves. 

Spastic conditions of the sphincter muscle, interfer- 
ing with relaxation, constitute a rarer form of ischuria. In several 
cases I was able to make the diagnosis of this condition by noting that 
the slightest irritation of the neck of the bladder with the catheter 
produced violent contractions of the sphincter muscle, which closed 
down firmly on the catheter. This form of ischuria frequently follows 
catarrhal conditions of the mucous membrane in the region of the neck 
of the bladder. 

Tumors of the Bladder. 

The first suspicion of tumor of the bladder is aroused by hemor- 
rhage. The tumor bleeds without any special cause; the blood becomes 
mixed with urine and gives it a more or less bloody color; rarely pure 
blood is discharged. The hematuria is intermittent. As blood from the 
vagina may also cause bloody urine, catheterization is the only method 
of determining that the blood is derived from the urinary apparatus. 
While hematuria is not pathognomonic of tumors, since it occurs also 
with calculi, foreign bodies and ulceration, it is nevertheless more abun- 
dant in tumors than in any other condition. Other symptoms have no 
diagnostic significance and may be entirely absent if the tumor does not 
happen to be situated at the ti'igonum. 

Microscopic examination of the urine may reveal large 
pieces of tissue with the structure characteristic of neoplasm which are 
strongly suggestive of tumor of the bladder; but the diagnosis of 
neoplasm can never be made by a few separate cells. 

Combined examination of the bladder through the 
vagina and abdominal walls is very uncertain. Small soft tumors may 
not be palpable or may escape the palpating finger. If the tumor is 
hard and firmly seated in the wall of the bladder, it may be felt and 
located in the bladder if the abdominal walls are soft. If the bladder 
wall and its surroundings are infiltrated with carcinoma, palpation is 
quite easy. Exploration of the bladder with the finger is, however, 
a much more certain method, the size, seat and consistency of the tumor, 
the presence of ulcerations on the surface and, above all, the size of the 
pedicle and the condition of the surrounding wall are easily recognized, 



SPECIAL DIAGNOSIS 581 

and important diagnostic antl prognostic information is thus obtained. 
The procedure, liowever, necessitates dilatation of the urethra, which 
is not without danger, particularly if the tumor is necrotic, and may 
cause infection of the tumor itself or bring on hemorrhage by wounding 
its surface. For the same reason examination with the sound and 
catheter is not to be advised. Exploration of the bladder has been 
superseded b}^ cystoscopy and is employed onl)^ when the results of the 
latter method are uncertain. 

Even cystoscopy has to contend with technical difficulties in 
cases of tumor of the bladder, and the results are not infrequently quite 
misleading. The technical difficulties consist in the accompanying 
catarrh, the occurrence of hemorrhage when the instrument comes in 
contact with the diseased parts, and the interference with the move- 
ments of the cystoscope. Cystoscopic diagnosis consists in the main 
in the demonstration of a polypoid body projecting into the lumen of 
the bladder. This will not be difficult in the case of small tumors, as 
the entire tumor and the adjoining parts of the bladder wall can be 
brought into view at once. It is much more difficult when the tumor 
is so large that only half of it is brought into the field of vision; in that 
case the cystoscope must be moved about to obtain a view of the edge 
of the tumor and to determine its attachment to the bladder wall by 
means of the deep shadows which it throws. A circumscribed tumor 
clearly outlined against the normal surrounding wall is very apt to give 
the impression of a projecting tumor. Extravesical tumors, such as 
cervical myomata which invaginate the bladder wall, may produce a 
similar picture, but the bulging is usually less pedunculated and the 
investing membrane looks perfectly normal; whereas the surface of 
a vesical tumor is usually nodular, ulcerated, incrustecl and covered with 
mucus and blood. The diagnosis by means of cystoscopy is much more 
difficult in the case of broad, sessile tumors, which may be mistaken for 
membranous and edematous swellings of the mucous membrane, espe- 
cially if the surface is not ulcerated. Blood clots, collections of pus and 
abscesses may also be mistaken for tumors. In cases of this kind the 
diagnosis must be cleared up by repeated examination or by exploring 
the bladder. 

By means of cystoscopy we must further determine the nature of 
the tu mor. Benign p a p i 1 1 o m a t a and c a r c i n o m a t a are the only 
ones that have any practical importance. PapiUomata appear as 
branching, papillary trees, either solitary or, more frequently, arranged 
in dense masses, with their tops floating in the fluid; under favorable 
illumination the blood-vessels can be seen through the mucous mem- 
brane. The surface rarely appears bright red, as it is usually covered 
with mucus or incrustations; ulcerations and hemorrhages are not 



582 



GYNECOLOGICAL DIAGNOSIS 



infrequently seen. The proliferation as a whole projects into the bladder 
and often throws a distinct shadow. Carcinoma produces a variety 
of pictures. In some cases it looks like a papilloma and cannot be 
distinguished with the cystoscope from the above-described benign forms. 
In other cases the cancer forms a circumscribed tumor with a fairly well 
preserved surface, and breakdown occurs late. Others again lead to infil- 
tration of large portions of the wall and produce a flat prominence with 
a deeply ulcerated surface, covered with secretion and incrustations. 
To illustrate the method pursued in making a diagnosis of tumor of the 
bladder, I cite the two following cases, which were observed in my service : 

Case 34. Mi.ss S., 33 years old. Tenesmus for the past five to six years; hematuria 
at intervals for the past eight months and almost constantly during the past three to four 
months; occasionally pain during urination; no disturbance of the general health. 





Fig. 335. — Cystoscopic Picture of 
A Papilloma of the Bladder. (Modi- 
fied after Zangemeister.) 



Fro 336. — Cystoscopic Picture of 
A Carcinoma of the Bladder. (Modi- 
fied after Zangemeister.) 



Combined examination reveals a soft tumor in the anterior vaginal vault. The parts 
surrounding the bladder are free. 

Cystoscopic findings: Color and injection of the vesical mucous membrane 
normal. Immediately behind the sphincter on tlie anterior wall tliere is a hemispherical tumor; 
the surface is irreguliii-ly nodular and covered witli edematous, grayish-red, somewliat trans- 
lucent mucous membrane covered witli floating cysts; in places white precipitates of salt 
are seen. Immediately behind and to the right of this tumor is another about tlie size of a 
pigeon's egg, while a third tumor covers the entire trigonum. The surface of the anterior 
tumor is covered with villous, papillomatous excrescences, some of which are dendritic. The 
villi float in the fluid and contain a blood-vessel. 

Diagnosis: Papillomata of the bladder (Fig. 335). Suprapubic operation 
confirms the diagnosis. 

Case 35. Miss H. for tlie past six months has had tenesmus and burning during 
lU'ination; for the past four months bloody urine, and once a severe hemorrhage, the 
symptoms having increased recently; emaciation and loss of strength began six or eight 
months ago. Combined examination reveals in front of the uterus a somewhat movable 
tumor about as large as an egg, of approximatelj^ oval shape and Iiard consistency; the 
tumor has no connection with the uterus or adnexa. Sounding and exploration of the 
bladder were not employed. 

CystoscojMc findings: The roof, right wall, and floor of the bladder show normal 
mucous membrane; the right ureter is normal. On the left side a roundish tumor projects 



SPECIAL DIAGNOSIS 583 

into the bladder; the surface is fairlj^ smooth, consisting of whitish, mortified tissue with 
incrustation; the base of the tumor is circumscribed and shglitly polypoid, judging from 
the distinct, sharply outlined shadow thrown bj^ tlic tumor (Fig. 336). 

Diagnosis: Vesical tumor. 

A suprapubic operation confirms the above findings and the microscope shows epithelioma. 

Vesical Calculi. 

Vesical calculi do not produce characteristic symptoms in the 
female, and their presence is obscured for a long time by the picture of 
the catarrh which they produce. Sometimes they are discovered by 
a lucky accident, or they may be revealed by cystoscopy performed 
for the purpose of investigating the changes produced by the long- 
continued catarrh and determining the cause. It should be a rule in 
every case of severe and protracted catarrh associated with intense 
pain to examine for calculus. 

As in the case of tumors, the results of combined examination 
of the bladder through the vagina and abdominal walls are very unsatis- 
factory. In the first place, a calculus of moderate size may escape 
palpation altogether, particularly if it is surrounded by a thickened 
bladder wall. In ten cases occurring in my service I failed to diagnose 
calculus in this way, and three times I was unable to feel calculi larger 
than a hazel nut, the presence of which had been demonstrated by 
other means. In addition, calculi may be mistaken for other tumors, 
and even more frecjuentlv the diagnosis of calculus may be made when 
nothing is present. 

Fritsch describes a mistake of this kind in the following words: 

"A woman had had many bladder symptoms; she had certainly had gonorrhea and fre- 
quent attacks of cystitis. On examination I distinctly felt a stone in the bladder which could 
be disj^laced from riglit to left in a manner absolutely characteristic of calculus. I felt so sure 
of my diagnosis that I did not even examine with a metal catheter. The woman was anes- 
thetized for the purpose of extracting tlie calculus through the dilated urethra. While she 
was under anesthesia the introduction of the metal catheter showed that the bladder was 
empty. The bladder was then held to one side, and this showed that the tumor was situated 
outside of the viscus; later, under the administration of powerful laxatives, the tumor turned 
out to be a coprolith." 

Examination of the bladder with a catheter or calculus- 
sound yields much more reliable results. Not infrequently the calculus 
is recognized when the catheter is introduced for the purpose of with- 
drawing urine. This is mere luck, however, and occurs only when the 
stone happens to be on the floor of the bladder; often it is hidden in 
a pouch of the lateral wall and cannot be reached with a sound. With 
the finger, on the other hand, a stone can always be detected, unless 
it is hidden in a diverticulum and covered with proliferated mucous 
membrane. Still more valuable is the information obtained with the 
finger in regard to the size of the stone, its position, shape and degree 



584 



GYNECOLOGICAL DIAGNOSIS 



of mobility. With regard to the size, the cystoscope may be very 
deceptive. For this reason, palpation of the stone with the finger is 
of great value, particularly in the choice of operative methods. As the 
danger of infection is much less than in the case of tumors, and the 
urethra must in any event be dilated for the purpose of extraction, 
digital exploration ma}' be used more freely than in the case of tumors. 
For diagnostic purposes alone, however, the method should not be 
employed until after cystoscop}^ has been performed. 

Cystoscopy is the most reliable method for demonstrating the 
presence' of stone. To be sure, the examiner often has to contend with 
great difficulties. The accompan^dng catarrh maj^ be so intense that 
it is impossible to fill the bladder with clear fluid; incontinence 
is not infrequently present, making it impossible for the patient to 

retain the injected water; or the intense 
strangury ma}' cause premature expulsion. 




Fig. 337. — Ctstoscopic Picture of 
A Phosphatic C.iicULUS. (.Modified 
after Zangemeister.) 



Fig. 338. — Uric Acid 
Calculus in the Bladder. 
(After Casper.) 



Fig. 339. — Calcium Oxa- 
late Calculi in the Bladder. 
(After Casper.) 



Occasionalh' the calculus is so large, or situated so near the urethral 
orifice, that the cystoscope cannot pass it. But if all these difficulties 
can be overcome, the picture is usually so clear and beautiful that a 
single glance suffices for the diagnosis. The size, shape, surface, color, 
number and position of the calculi are extremel}^ variable. All these 
points are easily recognized and recjuire no special description. I 
refer to the cystoscopic pictures shown in Figs. 337, 338 and 339. 

With the exception of the rarer cases in which the stone is encap- 
sulated in a diverticulum, the calculus can always be found with the 
cystoscope; it is, however, impossible to effect an entrance into all the 
pockets contained in the bladder. 

By means of radiography the presence of a calculus in the 
bladder can be determined, provided it does not happen to be hidden 
behind the bone; but as the results of cystoscopy are so certain, there 
is no need to resort to the X-rays unless the other method fails on 
account of the above-mentioned difficulties. Radiography, however, 
has one advantage over all other methods in that it easily and 



SPECIAL DIAGNOSIS 



585 



without danger reveals the presence and position of metallic foreign 
bodies that form the nuclei of calculi (Fig. 340). The following fig- 
ures from a monograph by Zangemeister based on material from my 
service shows the comparative value of the various methods for the 
diagnosis of calculus. 

Among 12 cases of vesical calculi the stone was recognized but 
once by inspection (it projected from the urethra); once by direct 
palpation through a vesicovaginal fistula; five times with the sound 
or catheter; and five times it was found with the cystoscope alone. 




FiG. 340. — Skiagraph of Two Vesical Calculi lying side by side in the sagittal direction. Tlie nucleus 
of one of them is formed by a hairpin. (Original.) 



Foreign Bodies in the Bladder. 

Foreign bodies in the bladder are very frequent in women, and 
either as foreign bodies or as the nuclei of vesical stones are of great 
practical importance. The foreign body either gets into the bladder 
from without, as in the case of ligatures; or is introduced for therapeutic 
purposes into the bladder and urethra and unintentionally allowed to 
remain, as in the case of pieces of catheter, the remains of urethral 
pencils made of wax, cocoa butter or paraffin; or foreign bodes, such 
as hairpins, leadpencils and the like, are introduced into the urethra 
for purposes of masturbation. 

Occasionally the diagnosis of these foreign bodies is suggested 
by the patient's statements; but usually no positive information is 
obtained, because the patient either purposely conceals or does not 
know of the introduction of the foreign body. In such cases it may 



586 GYNECOLOGICAL DIAGNOSIS 

remain in the bladder for a long time, until it finally produces symp- 
toms, or a calculus forms around it and medical treatment is required. 

I have removed four vesical calculi that had formed around foreign bodies; in two the 
nucleus was a hairpin; in one, a golden pencil; and in the fourth, a small piece of paraffin. 

Cystoscopy is the surest and least dangerous method of diag- 
nosis. After the bladder has been carefully irrigated, the foreign body 
is usually seen without difficulty. Hairpins, pieces of catheter, and 
irrigators are easily identified in this way. 

In one case I had a great deaL of diiRculty in diagnosing a lot of roimd, dark-brown 
pellets which floated on the surface of the urine in the upper portion of the bladder and danced 
about at the slightest movement. After they had been flushed out they were found to be 
particles of cocoa butter. The patient had beon treated some time previously with urethral 
pencils made of iodoform. 

The X-rays give us very useful pictures in cases of metallic foreign 
bodies, either free or surrounded by vesical nuclei, particularly in 
regard to the position. 

Seiffart demonstrated the presence of a hairpin in the bladder by means of the X-rays 
alone, and photographed it by introducing the plate into the vagina. 

I myself found a hairpin which formed the nucleus of a vesical calculus and had it 
photographed (see page 58.5). 

On account of the danger of infection and the necessity of dilating 
the urethra, exploration of the bladder with the sound and finger is a 
less valuable method of diagnosis. 

Diseases of the Ureter. 

The gynecologist is interested in ureteritis, ureteral fistulse, and 
injuries and compression of the ureter. 

Ureteritis is always secondary and follows either cystitis (ascend- 
ing) or pyelitis (descending) ; hence in a case of cystitis or pyelitis the 
physician must determine whether the disease has spread to the ureter. 
Disease of the ureter in itself has no great clinical signifi- 
cance. It should be diagnosticated, however, because the 
ureter forms the connection between the kidneys and the bladder, and 
if it is diseased, it therefore indicates that involvement of the kidney 
or bladder is imminent or has already occurred. 

The diagnosis of ureteritis cannot be made by examining 
the urine, because cells derived from the ureter cannot be distin- 
guished from the deep bladder cells and the cells that line the pelvis 
of the kidney. Occasionally the occurrence of drawing or colicky pain 
in the course of the ureter may indicate that the canal is involved; 
but in general the subjective symptoms are of little diagnostic value. 
Cystoscopy also fails in most cases. Although the cystoscope or the 



SPECIAL DIAGNOSIS 587 

ureteral catheter may serve to demonstrate that urine containing inflam- 
matory morphologic elements escapes from the ureter, it is impossible 
to decide whether these elements are derived from the pelvis of the 
kidney or from the ureter exclusively. If the ureteral orifice and the 
portion immediately adjoining are diseased, the results of cystoscopy 
are somewhat more satisfactory, although it is usually impossible to 
see the mucous membrane itself. The thickness of the fold around the 
ureteral orifice is no criterion of infiltration of the wall, because the 
size of this fold is subject to great individual variations. The only thing 
that indicates disease of the ureter is circumscribed change in the mucous 
membrane surrounding the ureteral orifice; if this region is very much 
injected or covered with bullous edema, the ureter is probably diseased. 
Dilatation of the ureteral orifice due to ulceration is seen in descending 
tuberculosis and is a sign of value. A positive diagnosis of ureteritis 
can sometimes be made by direct palpation of the ureter, partic- 
ularly that portion which joins the bladder. (For the technique see 
page 94.) A cord which may be as thick as a pencil is felt on one or 
both sides, passing in a flat curve with the concavity directed upward 
from the vaginal vault to the lateral wall of the pelvis; the cords are 
usually sensitive to pressure. The greater the infiltration, the greater 
will be the distance of the ureter from the median line. 

Case 36. Pain in the region of the left kidney for two years; strangin-y with vesical spasm. 

The uterus lies somewhat forward. On the left side the ureter is distinctly felt as a 
cord the thickness of a pencil, running from the anterior vaginal vault to the pelvic wall; the 
infiltration ceases exactly at the point which corresponds to the ureteral orifice in the 
bladder. The ureter is moderately sensitive to pressure; the right ureter is merely somewhat 
thickened, and also distinctly felt in its course to the pelvic wall as a cord the thickness of a 
wooden knitting-needle. The median extremities of the two lu'eters are about 2 cm. apart; 
at this point soft bladder wall is felt. 

Cystoscopy reveals a normal mucous membrane, except that the floor of the 
bladder is somewhat reddened; in the region of the left ureteral orifice there is seen bullous 
edema with transparent, closely packed vesicles, among which the left ureteral orifice is hidden; 
on the left side there is no flow of urine; on the right the urine is always clear. 

Gonorrhea and tuberculosis are the only diseases of the ureter 
that have any practical importance; they can be recognized only by 
the general picture. Occasionally the ulcerous destruction of the ureteral 
orifice may point to tuberculosis. Schrader in one case succeeded in 
making a diagnosis of tuberculosis by completely emptying the bladder 
and expressing the ureter bimanually, when he found tubercle bacilli 
in the urine. 

For the diagnosis of ureteral fistulae see page 576. 

The diagnosis of injuries of the ureter, whether by ligation 
or division, has assumed great importance now that abdominal opera- 
tions have become so extensive and frequently bring us into collision 
with the ureters. 



588 GYNECOLOGICAL DL\GNOSIS 

Bilateral complete ligation of both ureters is followed by complete 
anuria and the appearance of uremic symptoms, which, however, 
sometimes do not develop until some daj^s after the accident. If no 
urine is secreted during the second twenty-four hours after the opera- 
tion, ligation of both ureters should be suspected, as even the severest 
degree of prostration after a protracted operation attended with great 
loss of blood and the use of a large quantity of chloroform rarely pro- 
duces anuria lasting more than twenty-four hours. In view of the 
importance of making an early diagnosis of this fatal complication, 
the steps which are employed for establishing the diagnosis must not 
be delayed longer than about thirty-six hours, or until the first appear- 
ance of uremic symptoms. Cystoscopy alone, even in the form of chromo- 
cystoscopy, does not help us with the diagnosis; for, if urine escapes 
from the ureters at all, it will be found in the bladder with the catheter; 
and even the complete absence of the urinary stream from the ureteral 
orifice is not enough to exclude some profound functional disturbance. 
The introduction of a ureteral catheter is the only certain means of 
making the diagnosis, as the instrument is arrested at a definite point, 
indicating the presence of the obstruction. It must be remembered, 
however, that after an operation the ureter may be displaced and 
difficult to catheterize on that account, or there may be a complete 
kink in the canal. This is all that can be accomplished with the ureteral 
catheter, but at least it supplies the indication for immediate operative 
revision of the ureters. 

Ligation of one ureter rarely produces uremic symptoms or any 
marked diminution in the cjuantity of urine. If the other kidney is 
sound it undertakes the function of its fellow, sometimes with a slight 
disturbance of the quantity of urine, and the general condition soon 
becomes normal again. The only subjective symptom that might arouse 
a suspicion of the accident is a sudden pain in the region of the corre- 
sponding kidney. For this reason, chromocystoscopy and catheteriza- 
tion of the ureter, which are necessary for confirming the diagnosis, 
are usually not performed, and in most cases the ligation is unexpectedly 
discovered at the autopsy; or, if the patient survives, remains undis- 
covered as long as she lives. In rare cases ligation of one ureter leads 
to hydronephrosis, which can be recognized by its characteristic signs 
(see page 593, et seq.) and demonstrated by means of cystoscopy. 
Occasionally the ligature divides the catheter, and the urine which 
escapes through the opening infiltrates the tissues; or, if it makes its way 
to the outside, produces the symptoms of ureteral fistula. If attention 
has been called to the possibility that one ureter may have been ligated, 
the fact can be confirmed with the cystoscope by finding the correspond- 
ing ureter absolutel}^ 'dead' and impermeable to the ureteral catheter. 



SPECIAL DIAGNOSIS 589 

^ Operative division of the ureter is frequently discovered during 
operation, or immediately after, when the specimen is examined. If 
it is not recognized and there is no suspicion of the accident, the diag- 
nosis is usually impossible; for, if the urine is discharged into the free 
abdominal cavit}', there may be no reaction whatever if the urine is 
free from germs, and the wound runs an entirely aseptic course until 
the secretion of the kidney finally ceases. But the accident usually 
occurs during severe operations that do not run an aseptic course, so 
that peritonitis almost alwaj^s develops at once and obscures the picture 
of division of the ureter. If the division is extraperitoneal, the tissues 
become infiltrated with urine and an abscess is formed; if it is divided in 
the vagina, the symptoms of ureteral fistula soon make their appearance. 
Compression of tlie ureters may be caused by large, hard abdominal 
tumors, by a carcinoma growing around the ureter, or by cicatricial 
contraction of exudates. The diagnosis of the cause of compression is 
important in determining the question of its removal. The necessity of 
demonstrating the existence of compression is suggested by the occurrence 
of uremic symptoms in cases of bilateral compression, or when it is 
desired to determine the extent of a carcinoma which is to be removed. 
Incomplete compression does not produce distinct symptoms; but if the 
occlusion is complete, the absence of the urinary stream is discovered with 
chromocystoscopy, or the impermeability of the ureter by catheteriza- 
tion. These procedures are often rendered very difficult on account of 
the displacement of the floor of the bladder in the case of large tumors. 

Diseases of the Kidneys. 

Although diseases of the kindeys belong to internal medicine and 
surgery, the diagnosis of some kidney diseases must be discussed in 
this connection. They are pyelitis, on account of its direct connection 
with diseases of the bladder; tumors of the kidney, which are 
frequently apt to be mistaken for genital tumors; and movable kid- 
ney, which is a frequent concomitant of gynecologic diseases. The 
dividing line between gynecology and general surgery may be drawn 
at the ureter, allowing to the former ureteral fistula and operative 
injuries; but from the diagnostic standpoint the gynecologist cannot 
altogether ignore the kidney. 

Diagnosis of Pyelitis. The form of pyelitis which is most fre- 
quently seen by the gynecologist is that which follows cystitis of 
gonorrheal or tuberculous origin, or which is the result of infection by 
other organisms (catheter cystitis). In acute cases it is 

Pvclitis 

usually not difficult to determine whether the inflamma- 
tion in the bladder has extended to the pelvis of the kidney if the 
region of the kidney is very sensitive to pressure and there is high 



590 GYNECOLOGICAL DIAGNOSIS 

fever, usually lasting from four to six clays and recurring in similar 
attacks' at intervals. In subacute and chronic cases the cjuestion is 
more difficult to solve. Attempts to discover diagnostic points in 
the urine have failed. The caudate epithelial cells which were for- 
merly regarded as pathognomonic also occur in the bladder, and an 
acid reaction, which is said to be characteristic, is present also in gon- 
orrheal and tuberculous catarrh of the bladder. The quantity of pus 
in the urine and the degree of alkalinity may be so variable in pyelitis 
that the finding of a large quantity of pus does not necessarily indicate 
involvement of the pelvis of the kidney. An abundant amount of albu- 
min, with a small c^uantity of pus, in the urine is somewhat more sug- 
gestive. The symptoms, which consist in renal colic and lumbar pain, 
may suggest disease of the pelvis of the kidney; but the only way to 
make a positive diagnosis is by means of cystoscopy. In those cases in 
which pyelitis follows cystitis, the changes described on page 568 will be 
found in the bladder wall; when the ureteral orifice is carefully observed, 
turbid urine will be seen to escape in cases of purulent pyelitis. This 
turbid urine is at first easily distinguished from the clear injected water, 
until it finall}^ becomes intimately mixed with it. In other cases, par- 
ticularly if the secreting parenchyma has been destroyed, pure pus 
may be evacuated. Tlie cystoscopic diagnosis is more difficult if the 
urine coming from the kidneys is only slightly turbid and contains so 
few morphologic elements that it cannot be clearly distinguished 
from the injected water; on the other hand, particles of the bladder 
wall suspended in the fluid may sometimes seem to be derived from 
the ureter. The urine must be obtained directly from the ureter in 
order to make a positive diagnosis. But the introduction of the cath- 
eter in the presence of cystitis requires great care and certain special 
precautions to avoid transmitting the infection to the ureter. The 
bladder must be cleansed as well as possible by prolonged irrigation 
with a disinfecting solution (Casper recommends oxycyanide of mer- 
cury 1:5000), and contact of the catheter with any flakes of pus that 
may be present must be avoided. Great care is necessary in introducing 
the catheter in order to avoid causing erosions, which easily become 
infected; and the instrument must not be pushed in more than about 
5 to 10 cm. If these precautions are observed, the few bacteria that 
are introduced in spite of them usually do not set up an inflammation, 
because they are washed out again by the stream of urine. Casper 
recommends flushing out the ureter through the catheter with a few 
cubic centimeters of 1 : 1000 silver nitrate solution, and reports numerous 
cases in which the observance of these precautions enabled him to cath- 
eterize the ureters in the presence of a cystitis without causing infection. 
When special care is necessary, as for example in the case of tuberculosis 



SPECIAL DIAGNOSIS 591 

of the bladder, the urine segregator (Fig. 341) may be tried. The model 
designed by Luys is the best. It has the shape of a sharply curved male 
catheter and consists of three parts: two lateral gutters with a small 
opening in front, and a stop- cock behind for drainage, and between them 
a smooth, uniformly curved portion covered with a thin rubber tube 
which can be stretched out in the shape of a septum by means of cogs 
and chain worked from behind. The introduction of the instrument 
in females is exceedingly easy. The apparatus, consisting of three 
pieces, is introduced closed, and the septum opened by turning a 
screw. If the instrument is in the median line, and the floor of the 
bladder is pushed slightly forward toward the vagina, the bladder will 
be divided into two portions, in which the two halves of the 
double catheter will collect the urine separately from each ureter 
and conduct it into a glass tube attached to the instrument. One 




Fig. 341. — Urine Segregator after Luys. 

cannot, however, be absolutely sure that the urine is obtained separately 
from the two ureters, although in most cases it is possible to do so. For 
this reason the segregator is inferior to catheterization of the ureters 
and should be employed only when the latter method is contraindicated. 

After the ureteral catheter has been placed in position, the ureter 
should be allowed to contract a few times in order to flush out whatever 
may have gotten into the ureter from the bladder (Casper), after which 
a few cubic centimeters of urine are obtained for the purpose of exam- 
ining the sediment (because if the catheter is allowed to remain too long, 
formed elements derived from the ureter may be added to the urine); 
and finally the quantity necessary for chemical examination is drawn off. 

If cuboidal epithelial cells, pus corpuscles and blood in recogniz- 
able ciuantities are found in the sediment, and albumin is present in the 
filtered urine, a diagnosis of purulent p3^elitis may be made. 

The form of pyelitis is determined by the organisms which are found 
in the urine; tubercle bacilli should be looked for with special care. 

It is impossible by any known diagnostic method to determine 
whether or not the renal tissue is also involved in the pyelitis; the most 
reliable sign is the quantity of albumin. 

The following shows how cystoscopy and catheterization of the 
ureters, with other methods of examination, may lead to a diagnosis. 



592 GYNECOLOGICAL DL\GNOSIS 

Case 37. Mrs. G. The patient has been complaining for the past eight months of 
increased, and somewhat painful micturition, with dragging pains in the region of the right 
iireter. The urine is very turbid and contains an abundance of pus. With the cystoscope 
the mucous membrane of the bladder is found to be normal; but from the right ureteral 
•orifice, which is rigid and contracts sluggishly, large quantities of pus and tissue debris are 
discharged like the eruption from a crater; the urine coming from the left ureter appears to 
be clear. In order to obtain positive information in regard to the state of the left kidney, 
a Luys' segregator was introduced. On tlie riglit side the urine contained a quantity of pus 
large enough to fill half of a glass receptacle, while on the left, the urine was barely turbid, which 
could easily be attributed to pollution from the right side. An attempt was then made to 
palpate the iireters through the vagina, and on both sides, but particularly on the left, a 
distinctly thickened and painful ureter was found. The left side having thxis been shown 
to be diseased, a catheter was .introduced into the left ureter with the necessary precautions; 
the urine was slightly turbid and contained large numbers of epithelial cells from the pelvis 
of the kidney. In spite of the absence of tubercle bacilli the diagnosis of tuberculosis was 
made because tlie left lung was tuberculous. 

Diagnosis of Renal Tumors. Definition. For the purpose of 
diagnosis the term 'renal tumors' may be made to include a number of 
morbid conditions of the kidney associated with distinct enlargement 
Diagnosis of of the orgau. Retention tumors owe their origin to 
Renal Tumors. ^|^g accumulatiou of uriue containing mucus or pus (hydro- 
nephrosis and pyonephrosis). The neoplasms encountered are car- 
cinoma and sarcoma. The gynecologist is interested in renal tumors 
because they are often mistaken for ovarian tumors, and in this con- 
nection it will be enough to discuss the diagnosis of renal tumors as such 
without going into the distinction of the different forms. 

Some knowledge of the anatomy of the parts is necessary for a 
better understanding of the special properties of renal tumors. The 
posterior surface of the kidney is in relation with the quadratus lum- 
borum and transversalis muscles, from the last thoracic to the first two 
or three lumbar vertebrae. Above, it extends to the twelfth rib and 
sometimes a little higher; the inferior pole often extends to the crest 
of the ilium. The left kidney is usually somewhat higher than the right. 
In the median line the kidney is bound by the psoas muscle. The organs 
are surrounded by soft, fatty tissue; the kidney is not covered by peri- 
toneum, and the presence of a portion of peritoneum forming a kind of 
mesentery is pathologic. The large intestine is situated in front of, 
and a little to the outer side of the kidneys; the right hepatic flexure 
in front and to the right, and the descending colon in front of the left 
kidne}^ The ascending colon covers the lower pole of the kidney, 
follows the inner surface of the viscus to the level of the liver, 
and there forms a right angle and becomes the transverse colon. 
The splenic flexure is in relation with the upper pole of the left 
kidney, and from this point the descending colon descends alongside 
of the viscus. The relations between this portion of the large intes- 
tine and the peritoneum vary; but as a rule the posterior periphery 



SPECIAL DIAGNOSIS 



593 



of the bowel, which is in contact with the side and upper pole of 
the kidney, is entirely extraperitoneal (Fig. 342). 

The most important supports of the diagnosis are the position of 
the renal tumor and its relation to the large intestine. 
Small tumors produce practically no change in the position of an other- 
wise normal kidney; but as they increase in size they grow Position of 
chiefly to the outer side and forward, because they are Renal Tumors. 
prevented from growing inward by the vertebral column. In doing so 
they separate the peritoneum from the lateral wall of the abdomen and 
push the reflection of the peritoneum, which is found in the anterior 
abdominal wall, farther forward. The tumor is always extraperitoneal 
at the posterior and lateral wall of the abdomen; as it continues to grow 




Fig. 342. — Horizontal Section through the Abdominal Cavity in the Region of the Kidneys. 

grammatic.) (Original.) 



(Dia- 



it reaches the anterior abdominal wall above, under the arch of the ribs, 
while the inferior pole grows down toward the pelvis. If the enlarge- 
ment continues, the growth oversteps the median line, causes distention 
of the other side of the abdomen also, and descends into the true pelvis; 
hence an extramedian position and immobility of the tumor, 
owing to its extraperitoneal growth (providing the kidney is not 
movable), are the most characteristic features of renal tumor and are 
easily recognized. The palpation of small tumors may be difficult and 
may require a favorable attitude with relaxed abdominal walls, and pos- 
sibly anesthesia. The woman should be examined in the dorsal or in the 
lateral position, both hands being used. One hand is placed under the 
renal region and the other on the tumor. Mobility may be entirely abol- 
ished, or present only in a slight degree in the parts directed toward the 
abdominal cavity. Firm and tense tumors situated in the renal region as 
far as the vertebral column are easily palpated; if not, they may be 
38 



594 



GYNECOLOGICAL DIAGNOSIS 



demonstrated by the constant absence of the intestinal note on percussion 
at the affected site. In the case of large tumors, also, it can usually be 
determined without difficulty that one side of the abdomen is free and 
that the tumor extends on the other side into the lumbar region (Fig. 
343). If, however, the tumor forms in a movable kidney, or has produced 
a movable kidney by dragging on the peritoneal investment, the tumor 
may be depressed into the umbilical region and even deeper; but it can 
be pushed back into the lumbar region unless it has become adherent 
in its new position. The percussion note over a tumor containing a 
movable kidney may show intestinal tympany because the peritoneum 




Fig. 343. — Horizontal Section through a Ren.4x, Tumor in Situ. (Diagrammatic.) (Original.) 

has been drawn out to form a wide band, and the tumor is farther 
removed from the posterior abdominal wall. 

The relations of the renal tumor to the large intestine 
are even more important. As the renal tumor grows, whether on the 
right or left side, it forces the colon away from the lateral wall of the 
abdomen, so that the bowel is usually found along the inner side of the 
tumor. Large tumors may be behind the lower portion of the ascending 
colon, and the latter in this case will occupy a vertical position in front, 
and to the inner side of the tumor; while the hepatic flexure of the colon 
forms an oblic^ue, ascending line, merging with the transverse colon 
(Fig. 344) and draped, as it were, over the top of the tumor. When 
the tumor is on the left side, the descending colon above usually lies 
vertically in front of the tumor; while the sigmoid flexure, on account 
of its well developed mesentery, is not much altered in position. This 



SPECIAL DIAGNOSIS 



595 



change in the position of the colon maj^ almost be called a law, 
although it is subject to a number of exceptions, as when the tumor 
grows forward along the inner side of the intestine and displaces 
the latter outward. If a right-sided tumor grows downward under the 
cecum toward the pelvis, the cecum is displaced upward and is in con- 
tact only with the upper portion of the tumor; if there are inflamma- 
tory adhesions attaching coils of intestine to the surface of the tumor, 
or to one another, the bowel is not displaced at all or the displacements 
are irregular. The presence of the large intestine on the tumor is usually 
easy to determine; while it is empty it 
represents a flat ribbon which can be 
slightly moved to and fro on the tumor; 
and gurgling or purring noises are some- 
times present. Inflation with air renders 
the recognition somewhat easier; the 
inflation should be done with an atomizer 
through the rectum. As gases and fluid 
do not pass backward through Bauhin's 
valve, the accumulation of gas and fluid 
may be regarded as a specific sign that 
the structure is the large bowel. 

Before the introduction of cystos- 
copy, important diagnostic points were 
obtained from examination of the urine, 
since in the presence of a healthy 
bladder pus was regarded as pointing 
to pyonephrosis, and hematuria to a 
neoplasm of the kidney. At the present 
day, however, cystoscopy in con- 
nection with catheterization of 
the ureters has completely replaced the older methods. Although it is 
true that the diagnosis of renal tumor can be made in most cases with- 
out cystoscopy, nevertheless the method sometimes affords an important 
confirmation, and in doubtful cases provides the only basis cystoscopy in 
for the diagnosis. In a retention tumor with a completely E-enai Tumors, 
closed ureter, the canal will appear absolutely 'dead' when examined with 
chromocystoscopy; and when cystoscopy cannot be performed, the clos- 
ure of the ureter is directly felt when a catheter is introduced. The clos- 
ure of the ureter and absence of urinary flow are recognized by catheteri- 
zation of the ureters. If the ureter is still permeable, bloody or purulent 
urine, or pure pus, or even particles of tissue will escape in the case of renal 
tumors. In the case of open sacs, particularly pyonephrosis, the diagnosis 
is readily made by seeing the pus escape from the corresponding ureter. 




Fig. 344. — Renal Tumor of the Right 
Side. P.-F. %. The ascending and trans- 
verse colon pass obliquely over the tumor 
and are empty. The tumor is extraperitoneal 
and immovable. 



596 GYNECOLOGICAL DIAGNOSIS 

Case 38. Mrs. R. On the right side a renal tumor about the size of a man's head, 
exhibiting all the characteristic palpatory signs. On cystoscopic examination the bladder 
is found to be perfectly normal; the left ureteral orifice is very small, and clear urine is 
discharged; the right is greatly reddened and injected, and projecting from it is a thick 
drop of pus. Pressure on the tumor is followed after a few seconds by the discharge of thick 
pus in the shape of a small sausage, which sinks in the injection water and slowly dissolves. 
After extirpation the tumor was found to be a right-sided pyoneplirosis with calculus. 

Differential Diagnosis. The gynecologist is interested solely 
in the distinction of renal tumors from ovarian tumors. Confusion 
of the two conditions is possible only when the renal tumor is large enough 

to extend into the pelvic inlet, or the ovarian tumor reaches 
Difgno^lrfrom up to the region of the kidney, which may occasionally 
Tumors occur in the case of small tumors that have ascended with 

the gravid uterus, or have been prevented from descending 
during the puerperium by the formation of adhesions in the lumbar 
region. Small ovarian tumors with long pedicles may also be displaced 
into the lumbar region. The chief point of distinction is that renal tumors 
have no direct connection with the uterus, and that both ovaries can 
sometimes be felt underneath the tumors; whereas ovarian tumors are 
more or less distinctly connected to the uterus by a cord. But as this 
cannot be positively demonstrated in a number of cases, the above- 
mentioned characteristic signs of renal tumor also assist in the diagnosis. 
An ovarian tumor rarely occupies only half of the abdomen, leaving the 
other half entirely free. In most cases intestinal tympany is obtained 
at the outer side of the tumor, but in the case of renal tumors the per- 
cussion note is usually dull in that region. While renal tumors by 
traction on their peritoneal covering may develop a certain degree of 
mobility, they are always more or less adherent above and impeded in 
their downward movement; whereas in ovarian tumors the opposite 
conditions obtain. Ovarian tumors never exhibit the same relations to 
the colon as renal tumors; at all events, they are never placed behind 
the upper portion of the ascending or descending colon. The trans- 
verse colon, however, may lie along the top of a large ovarian tumor, 
and large subperitoneal growths may be placed behind the cecum on 
the right side and behind the sigmoid flexure on the left. The cecum and 
sigmoid flexure are easily recognized by their shape, especially the latter 
by its long mesentery. In difficult cases resort must be had to cystos- 
copy and catheterization of the ureters. Valuable information may 
also be obtained from the history and symptomatology. If the 
appearance of a tumor has been preceded by renal symptoms, i.e., renal 
colic and persistent pain in the lumbar region, or if the patient knows 
that the tumor started in the lumbar region and grew downward, the 
tumor is probably renal. Slow growth and the appearance of the tumor 
during childhood are much more frequent in the case of renal tumors. 



SPECIAL DIAGNOSIS 



597 



The following case illustrates the difficulties of a differential 
diagnosis between ovarian and renal tumors: 

The liistory contains nothing characteristic. 

The growth of the tumor is said to have begun below; the abdomen is greatly dis- 
tended by a cystic tumor twice as large as a man's head, and entirely in the median line. In 
the left lumbar region there is distinct tympany; in the right, the note has a tympanitic ele- 
ment. On the right side tlie right lobe of the hver is distinctly palpable in intimate contact 
with the tumor, and projects four fingers' breadth beyond the arch of the ribs. A loop of 
intestine is felt on the left side of tlie tumor, somewhat movable on the surface; tliis can be 
inflated, but the air does not advance beyond a certain point (Bauhin's valve). 

The uterus is small and lies underneath the tumor; the right ovary is palpable; the 
left cannot be found. 



Neck of tumor 



. Left kidney- 



Abdominal 

cavity with 
loop of small 
intestine 




Abdominal 
cavity with 
loop of small 
intestine 



Ascending colon 



Tumor 



Fig. 345. — Right-Sided Renal Tumok. (Original.) 



Nothing of any importance is found in the urine. Cystoscopy was not performed for 
practical reasons (judging from the final diagnosis it would probably have shown normal 
urinary secretions from both ureters). 

The diagnosis lies between left-sided ovarian tumor and right-sided renal tumor. 

In favor of ovarian tumor are the median position, the percussion note in the two 
lumbar regions, the absence of the left ovary, and the history. 

In favor of renal tumor are the position of the colon on the tumor, and, as the manner 
in which the air entered during inflation showed it to be the cecum, it could only be a right- 
sided renal tumor. 

Operation revealed a right-sided renal tumor. A neoplasm had probably developed 
in a movable kidney, which explained the median position and the distinct tympany on the 
side on which the tumor originated. The left ovary was not absent, but was foimd above, 
pressed against the abdominal wall. The anatomic relations are shown in the accompanying 
transverse section (Fig. 345). 

Microscopic examination revealed a sarcoma of the right suprarenal body. 

Diagnosis of Movable Kidney. Movable kidney is an exceedingly 
common complaint among women. The condition is suggested by the 
patient's complaining of distress in the lumbar region, or by the acci- 



598 



GYNECOLOGICAL DIAGNOSIS 



dental finding of a tumor on palpating the abdomen. In diseases which 
are often associated with movable kidney, such as enteroptosis, pen- 
dulous abdomen and prolapse, the patient should always be examined 
for displacement of the kidneys. 

In examining for movable kidney the patient must be placed in 
such a position as to relax the abdominal muscles and permit the kidney 
to leave its normal position. In other words, the woman should be 

placed on the sound side, with the 
knees slightly drawn up. In this posi- 
tion the kidney often slips down to, or 
beyond the navel. Examination after 
the patient has suddenly changed from 
the dorsal to the lateral position, or after 
active exercise is of advantage. If the 
abdominal walls are thin, the outline of 
the kidney can sometimes be seen; but 
as a rule the diagnosis must be made 
by palpation. One hand is placed 
under the lumbar region, the other flat 
on the abdomen in the hypochondriac 
region and, if the abdominal walls are 
not too thick, a tumor of the size, 
shape, and peculiar parenchymatous 
consistency of the kidney may be felt 
on deep inspiration. Occasionally the 
hilus, which is directed inward, is dis- 
tinctly palpable (Fig. 346), and under 
favorable circumstances the pulsating 
renal artery within the hilus; sometimes 
only the inferior pole of the organ can 
be felt. In such cases examination in 
the dorsal position after deep expiration is the best. If the displace- 
ment of the kidney is not very great, the organ is felt more easily in 
the sitting or standing posture with the trunk bent over forward. 
Movable kidney is further characterized by great mobility, so that 
it often slips away from between the fingers, and by the fact that it 
can be returned to its normal site. 

Absence of the kidney on the affected side, even if it can be positively 
demonstrated by palpation and percussion, is not a positive sign of mov- 
able kidney, as it is also observed in atrophy and ectopia of the kidney. 
Differential Diagnosis. A number of conditions which produce 
similar tumors in the lumbar region must be considered; but if the above- 
mentioned signs of movable kidney are borne in mind, there is practically 




Fig. 346. — Right-Sided Movable Kidney in 
THE Left Lateral Position. (Original.) 



SPECIAL DIAGNOSIS 599 

but one condition on the right side that may be mistaken for movable 
kidney. This is constriction of part of the hver substance (Schniirleber), 
which may be similar in shape and consistency to that of a movable 
kidne)^ It is sometimes difficult to demonstrate the connection between 
such a constricted portion and the liver, and cjuite frequently the mass 
is not movable with respiration; but it may be recognized by its sharp 
border, like that of the lower edge of the liver, and the fact that it 
cannot be replaced into the kidney site. 

The spleen is not very likely to be mistaken for a movable kidney, 
because the viscus does not appear below the arch of the ribs unless it 
is movable, which is a very rare condition. The spleen also differs from 
the kidney by its shape and notches. Sometimes the distinction can 
be made by attempting to replace the movable mass; if it is the spleen, 
it will return to the normal site of that organ underneath the arch of 
the ribs, while the kidney disappears in the depth of the abdomen toward 
the vertebral column. 

Partial contractions of the abdominal muscles may 
simulate movable kidney, but they disappear after a time and under 
anesthesia. Fibromata in the abdominal muscles may produce similar 
physical signs, but they are more superficial and have but little mobility. 

While the mere diagnosis of movable kidney by palpation is in the 
main easy, it may be difficult to decide in a given case what clinical 
significance the condition may possess. It must be remembered 
that in itself a movable kidney merely represents an anatomic abnor- 
mality, and in the vast majority of cases produces no symptoms what- 
ever. It can be called a pathologic condition and requires treatment 
for such only when the symptoms present can be positively referred to 
the movable kidney, and this is by no means easy. The most character- 
istic symptoms of pronounced displacement of the kidneys are the sudden 
attacks of pain, which are due to kinking of the pedicle, and which find 
their explanation in an acute hydronephrosis following kinking of the 
ureter, and sudden hyperemia with swelling of the kidney and tension 
of its capsule, following kinking of the veins. The attacks of pain are 
very intense, localized in the lumbar region, and accompanied by vomit- 
ing, colic, prolapse, weakening of the pulse, and syncope. At the height 
of the attack the kidney feels swollen and is very sensitive. Sometimes 
the symptoms disappear suddenly, as the obstacle subsides. There is 
another group of indefinite symptoms, such as drawing pains in the 
corresponding side, nausea, vomiting, pain in the stomach, pressure in 
the abdomen, and a variety of nervous phenomena; but these can be 
attributed to a movable kidney only if there is no other way of explain- 
ing them. Quite often the organ has to be replaced and fixed in its 
normal position before their etioiogic connection with the movable 



600 GYNECOLOGICAL DIAGNOSIS 

kidney can be definitely proved. Sometimes the patients are more 
definite' in their statements; they feel a movable body in the lumbar 
region which moves with every change of position; or they note 
the sudden appearance and disappearance of a tumor with certain 
movements of the body. Whenever the symptoms are indefinite, all 
other possible causes must be positively excluded, especially inflam- 
matory diseases of the adnexa and, in the case of right-sided movable 
kidney, appendicitis. 

Dystopia of the kidneys, or congenital position of the kidney in an 
abnormal place, interests the gynecologist because the organ is fre- 
quently found is the genital regions and may be mistaken for a tumor. 
The diagnosis of this condition is extremely difficult and has not 
been made more than once or twice in the living subject; nevertheless, 
dystopia is characterized by certain definite signs which might make 
the diagnosis possible, provided the condition was thought of. It should 
be remembered that the kidney must be retroperitoneal and therefore 
possesses but little mobility, and is in fact, as a rule firmly fixed to the 
body wall; it is usually to one side of the promontory in front of the 
sacro-iliac articulation, or on the anterior surface of the sacrum. An 
attempt should be made to outline the shape of the kidney by palpation. 
This can be done only if the organ can be reached through the vagina 
or rectum, or through the thin abdominal walls if it is situated on, or 
to one side of the vertebral column. If it is possible to make out by pal- 
pation the shape and consistency of a kidne)^, and especially the hilus, 
the diagnosis is not difficult; but as a displaced kidney is often atrophic, 
misshapen and lobulated (as during fetal life), and as hydronephrosis 
may form in a dystopic kidney, the difficulties are sometimes very great. 
If an artery can be felt in the hilus, as in some reported cases, it is a 
lucky accident. If at the same time the absence of the kidney from its 
normal position on the corresponding side can be demonstrated by 
palpation, it is another valuable diagnostic point. 

Catheterization of the ureters may yield important information. 
According to Mlillerheim, shortening of the corresponding ureter is a 
sign of dystopia. Since the flow of urine from the ureter is intermittent, 
while the flow is continuous from the pelvis of the kidney, Miillerheim 
measures the ureter by determining the difference in length on the cath- 
eter between the instant when the point enters the ureter and the instant 
when the continuous flow of urine from the pelvis of the kidney begins. 
Radiography is, however, a more certain method of recognizing dystopia 
of the kidneys. A lead catheter is introduced into the ureter of the 
corresponding side, and its course in the tumor definitely determined. 
If the dj'stopia is associated with complete atrophy of the kidney, which 
is not infrequently the case, the absence of renal function on the cor- 



SPECIAL DIAGNOSIS 601 

responding side, as determined by chromocystoscopy or catheterization 
of the ureters, or the absence of a ureteral orifice (T. Cohn), may 
assist in making the diagnosis. 

The following case came under my personal observation : 

Case 39. Mrs. Z. To the left of the sacral portion of the vertebral column a circum- 
scribed mass about as long as a finger and two finger's breadths wide, with a smooth surface, 
is felt, the inferior pole of which extends down to the promontory. The lateral border appears 
convex, while the median has a notched edge like a hilus. Along the upper edge a distinctly 
pulsating cord is felt running across the upper surface in a flat curve. The right kidney is 
palpable in its normal position, but the left cannot be found even after repeated careful pal- 
pation. The uterus and adnexa on both sides are normal. Diagnosis: Dystopia of the 
left kidney. Cliromocystoscopy shows a normal swelling around the ureteral orifice and the 
regular escape of urine from the canal; on the left side it is impossible to see either a normal 
orifice or a stream of urine during a period of observation of twenty minutes. A second 
examination gives the same result, hence the dystopic kidney is atrophic (T. Cohn). 

Differential Diagnosis. A kidney situated in the pelvis may 
be mistaken for a tumor of the genital organs. Depending on the spatial 
relations of the kidney to the ureters or adnexa, it may be mistaken 
for a myoma, a tubal tumor, or, if a h3alronephrosis has developed, an 
ovarian cyst. If the possibility of this renal abnormality were borne 
in mind, the diagnosis would no doubt be made more frequently from 
the above-mentioned signs. 

Ten years ago I saw a case in which I made a diagnosis of adnexal tumor based on the 
symptoms and tlie similarity of the physical signs. At the operation I satisfied myself by 
palpation that a dystopic kidney was present. 



Analytical Diagnosis. 



My original thought in writing the special diagnosis was to indicate 
the lines to be followed in making the diagnosis of a gynecologic 
disease. The methods of gynecologic examination are such that the 
information obtained by combined examination is very much more 
important than the symptomatology, which may, however, be of some 
assistance when the results of combined examination are not suffi- 
ciently definite. In a text-book a systematic treatment of the subject 
is absolutely essential, but it must be borne in mind that it does not 
represent the method which the physician must pursue in actual prac- 
tice in order to arrive at a diagnosis. Thus, for example, he will hardly 
go through the various stages of an examination for a myoma unless 
he already suspects the existence of such a tumor, or examine his patient 
for catarrh of the genitalia unless the diagnosis is suggested by the 
presence of certain symptoms. He who approaches a case without any 
preconceived ideas in regard to the direction which the diagnosis is 
likely to follow must at first reckon with the sum total of all known 
diseases. He will obtain the first hint from the patient's statements 
and must analyze the symptoms complained of in order to get a clear 
idea in regard to the seat of the particular disease in question. I have 
tried to meet this analytical need of the general practitioner by adopt- 
ing, as far as possible, an analytical method in the part devoted to 
special diagnosis, as in the diagnosis of diseases of the bladder, catarrh, 
new formations and ulcerations of the vulva; but in the case of most 
gynecologic affections this method is not applicable, and the first 
hint will be suggested by a single symptom or by first impressions. 
Thus, for example, displacement may suggest a myoma and the diag- 
nosis must then be confirmed or disproved by invoking the aid of all 
known diagnostic methods. If gynecologic processes were characterized 
by pathognomonic symptoms, these would indicate a definite line for 
the diagnostician to follow. Since however the opposite is the case 
and gynecologic symptoms consist in the main of hemorrhage, abdom- 
inal pain and vaginal discharge, and since they repeat themselves in 
a variety of forms in different gynecologic affections, the symptoma- 
tology has no practical diagnostic value. While an accurate observer 
who has an intimate knowledge of gynecologic symptoms may be able 
to arrive at a diagnosis by analyzing the most prominent symptom in 
the case and, with the aid of various secondary factors, resolving it 

602 



ANALYTICAL DL\GNOSIS 603 

into special subvarieties, such a method of procedure is beyond the 
ability of the less experienced general practitioner, although he also 
should try to attain his object in the same way. Such a knowledge of 
analytical diagnosis I consider particularly necessary to a physician 
in the interpretation of hemorrhage, the most frequent and the most 
important gynecologic symptom. In addition there are certain other 
gynecologic complaints which are so definite that they almost have the 
significance of a separate disease, particularly among the laity, although 
in reality they merely represent symptoms; they are amenorrhea, 
dysmenorrhea, and sterility. In the patient's mind severe pain during 
menstruation, the protracted absence of the menses, and sterility 
represent definite conditions which may be present without any other 
symptoms and often constitute the only reason for which medical advice 
is sought. The physician, however, must free himself from any such 
idea. To him these conditions are merely symptoms of a gynecologic 
or general disease, and their importance is enhanced by the fact that 
they occur in a great many quite different diseases. Hence he must 
proceed analytically and, after duly considering the special symptoms 
as well as'the general findings, strive to recognize the causal condition. 
For this reason I have added a section on the analytical diagnosis of 
hemorrhage, amenorrhea, dysmenorrhea and sterility, as well as a short 
discussion of abdominal tumors. (Tlie subject of vaginal discharge 
has been discussed in the chapter on the diagnosis of catarrh.) 



604 GYNECOLOGICAL DL\GNOSIS 



The Causes of Hemorrhage. 

A physician is often called upon to determine the causes of hemor- 
rhage from the genitalia because successful treatment usually pre- 
supposes correct recognition not only of the source, i.e., the bleeding 
organ, b\it also the cause of the circulatory disturbance. Quite often 
the question is solved coincidentally with the discovery of a genital 
disease known to have a tendency to hemorrhage, such as a uterine 
myoma; but not infrequently the genital disease itself cannot be 
regarded as the direct cause of the hemorrhage, as in the case of an 
ovarian tumor or a retroflexed uterus; or the palpatory findings may be 
normal, and the cause of the hemorrhage may be discovered only by a 
general examination of the entire body or a study of the history. Hem- 
orrhage is frequently the expression of functional disturbance and not 
a symptom of organic disease. 

To discover the cause of a hemorrhage the physician should 
proceed as follows: 

Certain historical data, such as the type of hemorrhage, i.e., 
whether menstrual (menorrhagia) or intermenstrual (metrorrhagia), 
must be determined. AVomen call any hemorrhage from the genitalia 
"period," whereas in a medical sense the term is restricted to the 
hemorrhage from the mucous membrane which occurs in the course of 
ovarian activity and coincident with the menstrual (monthly) conges- 
tion. It is often difficult to unravel the patient's statements. Some 
women calculate the duration of the menstrual interval from the begin- 
ning of the previous period and others from the end. For example, a 
woman may say that her period comes every two weeks, when in reahty 
she has an interval of two weeks and her period, which lasts a week, 
recurs every three weeks. The physician must therefore determine by 
judicious questioning the time when the menstrual flow occurs and the 
length of the interval, in order to get an idea of the type of hemorrhage 
he is dealing with. If the periods are variable in severity and duration, 
or the length of the interval is not constant, it may be very diflEicult to 
distinguish between menorrhagia and metrorrhagia, and in such a case 
it is best to note the date of the appearance of each hemorrhage and 
its duration. The problem is greatly simplified by keeping hemorrhage- 
charts, the didactic value of which was pointed out by Kaltenbach. 
I have introduced these charts (see Plate) with certain modifica- 
tions in my gynecologic service. They can be kept by the patients 
themselves and shown to the physician from time to time. One 



/ Types of Menstruation. 




IV 


Symptomatic haemorrhage in recent disease of the adnexa. 


























































August September October November December 1 Januarg 1 February 1 Mardi 


April 


fllag 

f, 10 IS 711 2S ;t 


s 1 


Tuue 


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1 1 li III 1 . , i .. 1 ... 1 


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V Carcinoma corporis with menorrhagia and irregular bleeding. 

Profuse. 




Winltr, DiOffitosii 



ANALYTICAL DIAGNOSIS 605 

glance at such a chart is often more instructive than a long and 
usually more or less confused statement from the patient. 
The type of the hemorrhage serves to indicate whether 

(a) The hemorrhage is menstrual (menorrhagia). The cause 
of menorrhagia may be anything that tends to prolong or increase the 
menstrual congestion, such as a recent adnexal disease; or which delays 
the completion of the menstrual flow, such as endometritis, relaxation 
of the uterus; or which leads to abnormal vascularity of the uterus, 
such as a myoma; or which modifies the regulating apparatus of the 
nervous system, such as general debility (Charts I, IV). 

(b) The hemorrhage is intermenstrual (metrorrhagia). The con- 
ditions in this form have nothing whatever to do with menstrual 
congestion; the hemorrhages are due to vascularity, as in carcinoma 
of the uterus, polyps, circulatory disturbances due to fright, acute 
inflammation (Chart V). 

(c) The hemorrhage is preceded by a variable period of amenor- 
rhea. The cause in this case is usually found in disturbances of the 
pregnant state (Charts II, III). 

In many cases the type of the hemorrhage is indicated by local or 
general molimina, which give the pathologic hemorrhage the character 
of a menstrual flow accompanied by the usual symptoms. 

The patient's statements with regard to the exciting cause of the 
hemorrhage, particularly if it is extramenstrual, may also be of value. 
The time of menstrual hemorrhage is determined by the menstrual 
congestion, but the time of occurrence and the course of the latter may 
be affected by local and general conditions of various kinds, such as hard 
physical work, nervous excitement or weakness, which have no diagnostic 
value. Extramenstrual hemorrhages require special causes for their 
occurrence and these causes are often external and easily recognized. 

They include traumatism, which may either affect the bleeding 
spot directly or produce rupture indirectly by increased pressure on the 
vessels. Coitus, vaginal irrigation and internal examination make up 
the direct traumatisms, but these occasional causes never produce 
hemorrhage from a normal mucous membrane. They presuppose an 
exposed tumor or a laceration, or a hyperemic mucous membrane covered 
with delicate cylindrical, instead of robust squamous epithelium. Hem- 
orrhage following coitus has a certain value as a pathognomonic sign 
of its most frequent cause, cancer of the cervix; although erosions, 
ulcerations and mucous polyps may bleed from the same cause. Coitus 
may also cause hemorrhage indirectly through the associated engorge- 
ment of the vessels. If the latter are friable, or their structure is altered 
as in endometritis and neoplasms in the uterine cavity, coitus may be 
followed by hemorrhage. Hence this type of hemorrhage points to a 



606 GYNECOLOGICAL DIAGNOSIS 

certain group of causes, as do also the hemorrhages which follow a 
vaginal examination or sounding performed with ordinary care; they 
point to disease of the mucous membrane, but do not admit of any 
definite conclusions in regard to its nature. Indirect traumatism such 
as occurs from hard work, the hfting and carrying of heavy loads, and 
causes vascular engorgement and hemorrhage by interfering with the 
return flow of the blood, also presupposes the existence of hyperemia, 
a neoplasm, or an ulceration, or the presence of a very vascular, delicate 
tissue su-ch as an ovum; a healthy mucous membrane rarely bleeds 
from this cause. Traumatism and hemorrhage of this kind accordingly 
point to endometritis, carcinoma, early pregnancy, etc. 

Nervous causes — violent excitement, fright or a severe cold — • 
may be responsible for the hemorrhage; but in such cases also it is 
probable that a local tissue change, or at least severe hyperemia of 
the mucous membrane with a tendenc}^ to hemorrhage, is present before- 
hand. Finally we must inquire into possible internal causes that 
may interfere with the normal course of menstruation; these include 
general debility, psychic depression and severe physical overexertion. 
Such conditions may materially affect the vasomotor apparatus even 
when the genitalia are normal. 

Of great importance are the hemorrhages during the meno- 
pause, i.e., hemorrhages that occur at least a year after complete 
cessation of the menses, a period long enough to indicate that the ova- 
rian function is completely abolished; uterine hemorrhages after the 
type of menstrual congestion are exceedingly rare after that period. 
As a rule such a hemorrhage is due to some definite disease — in the 
great majority of cases to carcinoma of the uterus or vagina (in about 
65 per cent, of the cases according to Neumann), more rarely to senile 
endometritis and colpitis, mucous polyps, a degenerated myoma, or 
diseases of the blood-vessels. All other causes that are capable of 
producing abnormal hemorrhage in sexually mature women under 
the influence of menstrual changes, such as endometritis, interstitial 
myoma, diseases of the aclnexa and internal diseases, have no etiologic 
significance after the menopause. 

The quantity of blood lost and the effect of the hemorrhage on the 
organism in general should receive some attention, although but little 
aid to the diagnosis is to be expected from that quarter. Such consider- 
ations are more important in a prognostic sense and in deciding the 
question of medical or surgical interference. 

A much more important step in the determination of the cause of 
the hemorrhage is the gynecologic examination, which may, 
if necessary, be made while the hemorrhage is going on. Although 
women object to examination while they are bleeding, the physician 



ANALYTICAL DIAGNOSIS 607 

should not shrink from contact with bleeding or menstruating genitalia 
and, aside from the fact that in the case of malignant growth precious 
time is lost by deferring the examination, there are certain important 
advantages in making it during the hemorrhage. In the first place it is 
easier to recognize a bleeding organ; again, as the cervical canal opens 
spontaneously during menstruation, a convenient opportunity for the 
recognition of intra-uterine polyps is afforded; and, finally, the appear- 
ance of the blood (see below) may aid in determining the cause of the 
bleeding. The source of the hemorrhage or, in other words, the bleed- 
ing organs should first be determined. External hemorrhage points to the 
vulva, vagina, vaginal portion, cervix and uterine body; 
blood from the tubes very rarely passes through the uterus and appears 
on the outside of the body. Hemorrhage from the bladder and rectum 
is not infrequently mistaken for a genital hemorrhage and, conversely, 
hematuria may be ascribed to an admixture of genital blood. In some 
cases catheterization or inspection of the stools, or careful inquiry into 
the history maj^ be necessary to avoid mistakes. The finding of the 
bleeding organ is often synonymous with the discovery of the morbid 
process which has produced the hemorrhage. In view of the great 
preponderance of corporeal hemorrhages over any other variety, the 
practised diagnostician will be inclined to direct his attention to that 
portion of the uterus at once; but the general practitioner will do well 
to adopt a surer method and examine the other organs also in regular 
rotation, beginning with the vulva. 

By inspection of the vulva it is easy to determine whether it is the 
source of hemorrhage, as the bleeding spot can be directly seen. If 
the mucous membrane is healthy, there must be some injury such as a 
fall, a blow, or coitus, which is the most frequent expla- 
nation of the hemorrhage. Ulcerations of the hymen some- 
times cause severe bleeding. Injuries near the urethral orifice, the clitoris 
and the perineum are sometimes produced during excessive and violent 
coitus. In pregnant women local changes such as varicose veins, which 
are readily recognized by their characteristic appearance, must be looked 
for. Breaking down carcinomatous and tuberculous lesions and, rarely, 
cancroid ulcerations may cause hemorrhage. Ulcerations of the vulva 
rarely bleed; syphilitic lesions may bleed after mechanical irritation, 
rarely spontaneously. If ulcerations of this kind are the source of the 
hemorrhage, the flow of blood may be seen directly or the ulcers may 
be covered with blood clots. The urethral caruncles not infrequently 
bleed either spontaneously or after injury. 

If the vagina is the source of the hemorrhage, the flow of blood 
from the vaginal wall is seen directly in the speculum, or changes such 
as are usually produced by hemorrhage are observed. A normal vagina 



608 GYNECOLOGICAL DIAGNOSIS 

does not bleed unless it is injured, usually during coitus, and bleeding 
lacerations can be either felt or seen. Among the changes recognizable 
by palpation which may be the source of the hemorrhage may be men- 
tioned carcinoma, sarcoma, gummata and decubital ulcers 
''"'°^' caused by the pressure of a pessary. Hemorrhages without 

palpable changes in the mucous membrane are seen in macular colpitis, 
especially in old women, because the squamous epithelium is attenuated 
and the vessels in the hyperemic papillae may be ruptured by the shghtest 
touch orv by a local increase in blood pressure. Mere contact with a 
cotton pledget may cause the blood to exude from the individual macules. 
It is not difficult to determine whether the vaginal portion is the 
source of the hemorrhage. Distinct palpatory changes may be present 
or, if the mucous membrane is intact, the hemorrhage may be directly 
seen in the speculum. Unless one of these conditions is present, the 
Vaginal blood is probably not derived from the vaginal portion. 

Portion. ^j^y condition in which the mucous membrane is destroyed 

by ulceration and in which erosion of the vessels takes place may be 
responsible for the hemorrhage — carcinoma, sarcoma, all kinds of ulcer- 
ative processes, such as tuberculous, syphilitic, cauterization- and 
decubital ulcers, rarely mucous polyps. Hemorrhage from an intact 
vaginal portion with well preserved squamous epithelium is exceedifigly 
rare. On the other hand, there are a number of alterations in the mucous 
membrane which may be the source of hemorrhage, such as erosions, 
circumscribed vascular engorgement of the papilla? similar to conditions 
seen in senile or maculous colpitis; so-called Fischel's erosions, or true 
ulcerations exposing the infiltrated stratum mucosum after separation 
of the squamous epithelium. Lesions of this kind are very apt to bleed, 
particularly after mechanical irritation such as that incident to coitus 
and a gynecologic examination, and in the presence of inflammatory 
disturbances resulting, for example, from physical overexertion or 
psychic excitement. But as these alterations of the mucous membrane 
do not always produce hemorrhage, and as they may be associated with 
disease affecting portions situated higher up which may also cause 
bleeding, it is important to decide whether the blood is really derived 
from the vaginal portion or whether the uterus is also the seat of hemor- 
rhage. Mistakes in this direction may be avoided by noting the type 
of the hemorrhage with reference to the causes found in the vaginal 
portion and by a systematic examination of the uterine body, which is 
a most frequent source of genital hemorrhage. In this connection I 
may cite the following cases: 

Case 40. Mrs. K. The patient has been suffering for some time from irregular, severe 
hemorrhages occurring without definite cause. Examination reveals a nmcous polyp of the 
vaginal portion almost as large as a walnut; but the hemorrhage is not of the kind that 



ANALYTICAL DL\GNOSIS 609 

corresponds to this tumor, as the patient complains only of severe menorrhagia, often lasting 
from two to tliree weeks. The endometrium is very rough and the diagnosis of fungous 
endometritis is therefore made and confirmed by microscopic examination of the scrapings. 
Case 41. Miss P., 68 years of age. Menopause 20 years ago; for the past 8 weeks 
slight bleeding at intervals and once a severe hemorrhage following an irrigation. The exter- 
nal OS contains a mucous polyp as large as a plum-stone, which is regarded as the cause of the 
hemorrhage. After this polyp had been twisted off, the bleeding stopped for 5 months; then 
it recurred and has been present with variable intensity for almost 7 montlis. At the present 
time no mucous polyp is found, but instead a distinctly thickened and retroflexed uterus. 
Curettage yielded large quantities of mucous tissue, apparently derived from a mucous 
polyp, wlaich was probably responsible for the original bleeding also. 

If the vaginal portion can be definitely excluded, the blood must 
be derived from the uterus. In that case the character of the hemorrhage 
is much more difficult to determine, because the bleeding spot cannot 
be directly seen or felt unless the changes are limited to the lower portion 
of the cervical substance, or the external os is widely dilated. The 
conditions to be examined for under these circumstances are carcinoma, 
sarcoma, myoma and mucous polyp of the cervix. The intact cervical 
mucous membrane does not bleed; and a diseased cervical mucous 
membrane much more rarely than that of the body because 

, . 1 , . , . , . , . Cervix. 

it IS not subjected to physiologic changes m vascularity. 
On the other hand, slight hemorrhage is observed in acute infec- 
tious catarrh with marked hyperemia of the mucous membrane 
and in chronic hyperplastic conditions with the development of small 
vascular polyps. 

If the cervix is also found to be ciuite healthy beyond the possibility 
of a doubt the hemorrhage m.ust come from the uterine body, as it is 
a more frequent source than any other portion of the genital apparatus. 
The diagnosis of uterine hemorrhages covers a large field, Body of 

including diseases of the uterus and adnexa, general theutems. 

organic and nervous diseases, and temporary disturbances of the cir- 
culation. To pick out the true cause from all these conditions is in my 
opinion one of the most difficult tasks that the physician is called upon 
to perform. Any bleeding other than that of menstruation is abnormal; 
excessive menstruation and irregular bleeding of every kind are path- 
ologic and must have a special cause. It is advisable in searching for 
these causes to follow a definite line of examination in order, if possible, 
to discover some objectively demonstrable disease. 

We first look for some disease of the uterus by determining, with 
the aid of palpation, the size, consistency and position of the organ, in 
the hope of finding some clue to the cause of the hemorrhage. 

If the uterus is distinctly enlarged, it may be a sign of disease of 
the wall or endometrium, viz., myoma, sarcoma, carcinoma, syphi- 
litic or chronic metritis in combination with chronic endometritis. The 
absence of enlargement, however, does not exclude the possibility of a 

39 



610 GYNECOLOGICAL DIAGNOSIS 

small submucous myoma or beginning carcinoma. (For the diagnosis of 
these conditions see the corresponding chapters.) 

If the uterus, besides being enlarged, is also softened, some 
disturbance of pregnancy suggests itself, such as hemorrhage from a 
gravid uterus in decidual endometritis, placenta prsevia or traumatic 
hemorrhage; hemorrhage in any state of abortion, retention of a dead 
ovum, or subinvolution after abortion or parturition. 

The only displacement of the uterus that needs to be considered 
as a possible cause of hemorrhage is retroflexion. When it is recent, and 
particularly during the puerperium, this condition produces acute metror- 
rhagia; while in chronic retroflexion menorrhagia occurs as the result of 
disturbances and relaxation of the uterus and its vascular apparatus. 

If no changes of this kind are found in the uterus by palpation, the 
cavity is to be explored with the sound. If the entire mucous mem- 
brane is found to be smooth it is probably healthy. Distinct roughness 
usually, but not always, indicates either benign (fungous endometritis, 
decidual remains) or malignant diseases (carcinoma, sarcoma of the 
mucous membrane). If the cavity appears to be irregularly contracted, 
submucous myomata may be present; but in that case the sounding 
should be confirmed by digital exploration and curettage (see the 
respective chapters). 

If the uterus presents nothing abnormal and cannot be regarded 
as the direct cause of the increased bleeding, the physician must turn 
his attention to the surrounding structures and look for the cause of 
these so-called secondary uterine hemorrhages in diseases of the adnexa, 
the peritoneum or the parametrium. 

Among tubal diseases we must consider recent or very large 

pyosalpinx, which often occasions protracted and profuse menstruation 

coming on ahead of time and sometimes quite irregular menses; acute 

exacerbations of tubal diseases are usually attended by 

Secondary . . i i • 

Uterine reucwed hemorrhage. Chronic tubal disease and chronic 

Hemorrhages t i i i , i t i 

adnexal tumors are much less likely to be the direct cause 
of purely secondary uterine hemorrhages; in most cases the hemorrhages 
are due to the coexisting endometritis. A tubal pregnancy if found is 
in some way associated with the uterine hemorrhages. If the fetus is 
alive, hemorrhage is absent or very slight; but after death of the fetus, 
in the presence of tubal mole and peritubal and retro-uterine hematocele, 
protracted hemorrhages usually occur. The bleeding is never derived 
from the tubal disease, as such a thing is inconceivable unless the orifice 
of the tube is dilated and the blood remains fluid; it is always due to 
congestion and subinvolution. 

In spite of the close relation existing between ovarian function 
and uterine bleeding under normal conditions, changes in the ovaries 



ANALYTICAL DIAGNOSIS 611 

rarely produce hemorrhage from the uterus. In rare cases an ovarian 
tumor that has developed on one side may cause metrorrhagia. A little 
more frequently the symptom is observed in the presence of bilateral 
tumors during the menopause and particularly when both ovaries are 
the seat of carcinoma. In most cases these hemorrhages are undoubtedly 
to be regarded as secondar)^; but as metastasis in the body of the uterus 
is possible, the endometrium should be examined with special care. 
Inflammatory ovarian disease occasionally causes uterine hemorrhage. 
In acute conditions irregular hemorrhages sometimes occur, while in 
chronic oophoritis irregular, protracted and excessive menstruation is 
not uncommon; whether these symptoms are also secondary or whether 
they are due to the accompanying endometritis is often difficult to decide. 

Another cause of uterine hemorrhage is found in pelvic peri- 
tonitis. In the acute stage and in acute exacerbations of chronic 
conditions irregular uterine hemorrhages of moderate duration may 
occur; these hemorrhages are purely symptomatic and frequently 
represent the initial symptoms of the disease. If metrorrhagia is present 
in chronic peritonitis with adhesions and exudation, an associated 
chronic endometritis is extremely probable, exoept in the case of large 
exudates, which may also produce congestive hemorrhages. Large 
collections of blood in the peritoneal space are almost always attended 
by uterine hemorrhage without any definite characteristics and extend- 
ing over several months. 

Diseases of the parametrium, whether acute or chronic, are 
very rare causes of uterine hemorrhage. Whenever the inflammation 
is chronic there must always be a suspicion of complicating endometritis 
as in the case of chronic peritonitis, especially if the bleeding presents 
the type of the menstrual flow. 

If the adnexa also fail to show signs of being the cause of the hem- 
orrhages, the physician is confronted with the very difficult and often 
impossible task of explaining a hemorrhage without any abnormal 
physical signs. It is needless to say that under these circumstances 
mistakes are necessarily very frequent, hence one should attempt to 
find the cause in some definite pathologic condition and not give too 
loose a rein to mere hypothesis. I shall accordingly confine myself to 
the discussion of those causes which are easily intelligible and universally 
acknowledged, and avoid mere possibilities. 

The causes of a hemorrhage without abnormal physical signs may 
be general or local and, since the latter are much more frequent, they 
should form the first object of investigation. There may be only a 
single, severe hemorrhage, or menorrhagia may occur with each 
menstruation. In the former case the hemorrhage may possibly 
represent merely an excessive menstruation, which is not recognized as 



614 GYNECOLOGICAL DIAGNOSIS 

admixture of mucus. The color is dark red (carmine) or black, the 
odor quite characteristic and sometimes slightly fetid. Clotting is 
prevented b}^ the genital secretions. The presence of recent blood 
that coagulates promptly points to a recently opened source, 
as in abortion, polyps, degenerating malignant tumors, particularly 
after digital exploration or sounding of the uterine cavity, in endo- 
metritis and in retention of decidual tissue. Coagula, commonlj'- 
described as 'pieces,' usually indicate that the hemorrhage has been so 
profuse tliat the alkaline secretions of the uterus have been insufficient 
to prevent coagulation. Coagula are always pathologic and occur 
when the menstrual flow is excessive, with abortion, polyps and degen- 
erated tumors; protracted hemorrhage of moderate severity, as in 
hematocele, is rarely accompanied by the formation of coagula. A 
dirty brown appearance of the blood indicates that it has been 
retained in the uterus for some time and subjected to chemical changes. 
The discoloration is most frequently observed in the hemorrhages of 
pregnancy, in which the last of the blood finally appears merely as a 
lemon yellow discoloration of the secretion. If the blood is intimately 
mixed with mucus, the hemorrhage is confined to the cervical 
mucous membrane, as in recent catarrh or polyps; or when corporeal 
hemorrhage is accompanied by an abundant secretion of mucus by the 
cervix, as in endometritis, the hemorrhages of pregnancy, and sub- 
involution after abortion and parturition. Inspissated blood of 
syrupy consistency is observed when the blood has been retained 
for some time in a closed cavity, as in hematocolpos and hematometra; 
true coagulation does not take place under these circumstances. 
Shreds of tissue in the blood point to degenerated neoplasms, 
or exfoliation and disintegration of portions of the mucous membrane, 
especially in cases of abortion with infection. 



ANALYTICAL DL4GNOSIS 615 



The Causes of Amenorrhea. 

Definition and Limitations of Amenorrhea. — Amenorrhea is the 
absence of menstruation in a sexually mature woman. In a wider 
sense the term should embrace all cases of amenorrhea, including those 
in which the menses are merely suppressed for one or two 

•^ ^'^ Definition and 

periods by temporar)^ causes such as exposure to cold Limitations of 
affecting the abdomen, _emotjon and the like. These are 
mere temporary conditions, however, and the physician is rarely called 
upon to determine their cause. The forms of amenorrhea which are 
brought to the physician's attention as such are always chronic condi- 
tions in which menstruation has been interrupted at least for several 
months. Amenorrhea in addition includes delayed menstruation 
and premature cessation of the menses. As menstruation 
usually continues so long as the ovarian function is preserved, any 
failure of menstruation during the period when ovulation is active 
must be regarded as abnormal. In the absence of clinical signs of ovula- 
tion we must fall back on our knowledge of the normal time of the first 
appearance of menstruation and of the menopause, which varies between 
fairly wide limits. Accordingly the physician is not often called upon 
to assign a cause for amenorrhea before the 20th or after the 40th year 
of life. For practical purposes these ages must be regarded as marking 
the limits of pathologic amenorrhea. Abnormal scanty menstruation, 
for which the patient often consults the physician in the absence of 
other symptoms and particularly if it is associated with sterility, is 
practically equivalent to amenorrhea in a climacteric and etiologic 
sense. The boundary line between scanty and. abnormally scanty men- 
struation is difficult to determine, unless the patient states that the 
menstrual flow has perceptibly diminished. 

Since amenorrhea signifies the complete absence of menstrual 
bleeding, atresia of the genital organs, in which the blood is merely 
retained, are here excluded from the diagnosis. 

The diagnosis of amenorrhea is based exclusively on the 
patient's statement that menstruation has failed to appear. 

The physician's duty consists solely in finding the cause of the 
amenorrhea. He is consulted because the patient wishes to know the 
reason why menstruation has not appeared or on account causes of 

of symptoms which are the result of amenorrhea (flushing, Amenorrhea, 
molimina, eczema), or sterility, or certain symptoms of the general 
disease which is the cause of the existing amenorrhea. Not infrequently 



614 GYNECOLOGICAL DL4GNOSIS 

admixture of mucus. The color is dark red (carmine) or black, the 
odor quite characteristic and sometimes slightly fetid. Clotting is 
prevented b)^ the genital secretions. The presence of recent blood 
that coagulates promptly points to a recently opened source, 
as in abortion, polyps, degenerating malignant tumors, particularly 
after digital exploration or sounding of the uterine cavity, in endo- 
metritis and in retention of decidual tissue. Coagula, commonly 
described as 'pieces,' usually indicate that the hemorrhage has been so 
profuse tliat the alkaline secretions of the uterus have been insufficient 
to prevent coagulation. Coagula are always pathologic and occur 
when the menstrual flow is excessive, with abortion, polyps and degen- 
erated tumors; protracted hemorrhage of moderate severity, as in 
hematocele, is rarely accompanied by the formation of coagula. A 
dirty brown appearance of the blood indicates that it has been 
retained in the uterus for some time and subjected to chemical changes. 
The discoloration is most frequently observed in the hemorrhages of 
pregnancy, in which the last of the blood finally appears merely as a 
lemon yellow discoloration of the secretion. If the blood is intimately 
mixed with mucus, the hemorrhage is confined to the cervical 
mucous membrane, as in recent catarrh or polyps; or when corporeal 
hemorrhage is accompanied by an abundant secretion of mucus by the 
cervix, as in endometritis, the hemorrhages of pregnancy, and sub- 
involution after abortion and parturition. Inspissated blood of 
syrupy consistency is observed when the blood has been retained 
for some time in a closed cavity, as in hematocolpos and hematometra; 
true coagulation does not take place under these circumstances. 
Shreds of tissue in the blood point to degenerated neoplasms, 
or exfoliation and disintegration of portions of the mucous membrane, 
especially in cases of abortion with infection. 



ANALYTICAL DIAGNOSIS 615 



The Causes of Amenorrhea. 

Definition and Limitations of Amenorrhea. — Amenorrhea is the 
absence of menstruation in a sexually mature woman. In a wider 
sense the term should embrace all cases of amenorrhea, including those 
in which the menses are merely suppressed for one or two 

Definition and 

periods by temporary causes such as exposure to cold Limitations of 
affecting the abdomen, emotion and the like. These are 
mere temporary conditions, however, and the physician is rarely called 
upon to determine their cause. The forms of amenorrhea which are 
brought to the physician's attention as such are always chronic condi- 
tions in which menstruation has been interrupted at least for several 
months. Amenorrhea in addition includes delayed menstruation 
and premature cessation of the menses. As menstruation 
usually continues so long as the ovarian function is preserved, any 
failure of menstruation during the period when ovulation is active 
must be regarded as abnormal. In the absence of clinical signs of ovula- 
tion we must fall back on our knowledge of the normal time of the first 
appearance of menstruation and of the menopause, which varies between 
fairly wide limits. Accordingly the physician is not often called upon 
to assign a cause for amenorrhea before the 20th or after the 40th year 
of life. For practical purposes these ages must be regarded as marking 
the limits of pathologic amenorrhea. Abnormal scanty menstruation, 
for which the patient often consults the physician in the absence of 
other symptoms and particularly if it is associated with sterility, is 
practically equivalent to amenorrhea in a climacteric and etiologic 
sense. The boundary line between scanty and. abnormally scanty men- 
struation is difficult to determine, unless the patient states that the 
menstrual flow has perceptibly diminished. 

Since amenorrhea signifies the complete absence of menstrual 
bleeding, atresia of the genital organs, in which the blood is merely 
retained, are here excluded from the diagnosis. 

The diagnosis of amenorrhea is based exclusively on the 
patient's statement that menstruation has failed to appear. 

The physician's duty consists solely in finding the cause of the 
amenorrhea. He is consulted because the patient wishes to know the 
reason why menstruation has not appeared or on account causes of 

of symptoms which are the result of amenorrhea (flushing, Amenorrhea, 
molimina, eczema), or sterility, or certain symptoms of the general 
disease which is the cause of the existing amenorrhea. Not infrequently 



616 GYNECOLOGICAL DL4GNOSIS 

amenorrhea gives the first hint of such a general disease. Various dif- 
ficulties are encountered in searching for the cause of amenorrhea. In 
some cases the cause is obvious as, for example, when the uterus is 
imperfectly developed; in other cases the diagnosis may remain in 
doubt after the most careful examination of the genitalia and of the 
entire body and the most careful weighing of all possible causes. The 
prognosis and treatment of amenorrhea depend solely on the correct 
recognition of the causes. These may be divided into local, i.e., 
such as reside in diseases and alterations of the genital apparatus, and 
general, i.e., causes which merely impair the menstrual function, 
such as wasting diseases, nutritional disturbances and profound neuroses. 
It must be admitted that this distinction cannot be carried out in all 
cases. In general infectious disease, for example, there may be a 
question whether the debilitating effect of the disease is the cause of 
the amenorrhea, or some local disease of the uterine mucous membrane 
has developed as a result of the infection and is interrupting the normal 
process of menstruation. In order to lay down the indications for suc- 
cessful treatment it is absolutely necessary, and in most cases it 
is also possible, to recognize or at least to exclude the local causes. 

It must be remembered that uterus and ovaries are necessary for 
normal menstruation; in diseases of either organ local causes may be 
present. Types of these two forms are seen in amenorrhea after extir- 
pation of the uterus and after oophorectomy. The physiologic amenor- 
rhea of pregnancy and lactation will be omitted from the discussion. 

In the examination of the genitalia for the purpose of 
finding the local causes attention should be directed first to the uterus . 
By bimanual palpation we determine whether there is a uterus, and if 
Uterine SO, its size aud thickness. The absence of a uterus or the 

Amenorrhea. presence of a rudimentary uterus is a certain cause of amen- 
orrhea, even if the ovaries are perfectly normal. On the other hand, if 
the uterus is found to be present, the sound should be introduced into 
the cavity for the purpose of determining its length and, with the exter- 
nal hand feeling for the head of the sound through the abdomen, the 
thickness of the uterine wall. Great care is necessary as the atrophic wall 
is easily perforated. Atrophy of the uterus is recognized by comparing 
the uterine cavity with the thickness of the wall. Two forms of atrophy 
are distinguished: in one the cavity is greatly shortened and the wall 
attenuated (concentric atrophy), in the other the cavity is of normal 
length but the wall is thin (eccentric atrophy). The former usually 
indicates severe atrophy with persistent amenorrhea, while the latter 
is generally a temporary condition. 

It is not always easy to determine whether the uterine atrophy is 
primary or secondary to atrophy of the ovaries. So-called fetal uterus 



ANALYTICAL DIAGNOSIS 617 

and infantile uterus, in which menstruation has never taken place, may 
be regarded as primary atrophy; while those cases which develop after 
menstruation has been going on for a variable length of time may be 
due to some primarj^ disease of the uterus or may be secondary. In 
these cases atrophy is usually less severe and often of the eccentric type. 
Some information may be obtained by examining the uterus and ovaries. 
If sounding the cavity shows it to be atrophic and partially obliterated, 
the local cause may be found in destruction and adhesions of the endo- 
metrium, such as occur after infectious puerperal processes, after the 
use of caustics, and after curettage, particularly during the puer- 
perium. If the cavity is open, the loss of tha uterine function must still 
be regarded as the cause of the amenorrhea, even if the ovaries are found 
on examination to be normal (see below) ; this type of amenorrhea 
occasionally occurs in endometritis and chronic metritis. The uterine 
atrophy which occasionally develops in the presence of large puerperal 
exudates is also local in character. In not a few cases, however, and 
especially if no general cause can be found, it must remain undecided 
whether the uterine amenorrhea is primary or not. From the thera- 
peutic standpoint it is better to regard it as a local uterine atrophy and 
to treat it accordingly by local measures. 

If no cause for the amenorrhea can be found in the uterus, the 
ovaries are examined, if necessary under anesthesia. The size is the 
only criterion that we have for their integrity. If they are normal in 
size, it is not likely that they are the cause of the amenorrhea. ovarian 

On the other hand, mere diminution in size is no proof Amenorrhea, 
that the alteration is primary; since atrophy of the ovaries follows 
uterine atrophy, both the primary form and that which depends on 
constitutional causes. Primary atrophy of the ovaries from local causes 
is very rare. In most cases some constitutional cause or internal disease 
which we are not always able to identify is present. Amenorrhea of 
purely ovarian origin is occasionally observed in the presence of bilat- 
eral, and especially malignant ovarian tumors, when associated with 
complete destruction of the essential ovarian tissue. It is also seen at 
times in chronic oophoritis with atrophy of the follicles. The molimina 
may help to decide whether an amenorrhea is ovarian or not. They 
consist in dragging and cramp-like pains in the two hypogastric regions 
and in the sacrum, which last several days and recur either every four 
weeks or at irregular intervals, when ovulation is normal and the menstrual 
congestion is not sufficient to produce a flow of blood. If the molimina 
are well marked, the case is usually one of primary uterine atrophy. 

Case 42. Miss H., age 18; has never menstruated. She says that for the past two 
years she has suffered very severe dragging and cramp-like pains in the abdomen occurring 
at quite irregular intervals. For the past four or five months these pains have occurred reg- 



618 GYNECOLOGICAL DL^GNOSIS 

ularly every four weeks, lasting from 6 to 8 days and increasing in intensity often to the point 
of syncope. During this time the patient is entirely incapacitated. Examination of the gen- 
italia shows entire absence of the vagina and a very thin, rudimentary, bipartite uterus. 
The right ovary is normal in size; the left is somewhat smaller (see Fig. 326). 

Case 43. Miss L., 19 years of age. First menstruation at the age of 13; menstruation 
comes on regularly every 4 weeks, lasting from 2 to 3 days, and the quantity is normal. Sev- 
eral years ago the patient caught a severe cold by wading in cold water during the menstrual 
period; tiiis was followed by suppression of the menses and complete amenorrhea lasting 18 
months. The menses then reappeared and have since then been irregular, sometimes coming 
on too early and sometimes too late, or with intervals sometimes as long as 4 montlis. A few 
drops of blood were discharged and there was severe dysmenorrhea whenever rhenstruation 
failed to appear, and the patient had severe molimina, consisting of cramp in the abdomen 
and headache. Examination revealed a uterus 41 cm. in length and of normal shape, with 
very tliin walls; both ovaries could be felt and were smaller than normal. 

Absence of molimina does not always prove that the ovaries have 
ceased to functionate, as may be frequently observed after hysterec- 
tomies in which portions of the ovaries are left behind. 

Amenowhea due to general and constitutional causes is much more 
frequent and of greater practical importance. If on combined exam- 
ination no very marked local changes are found, the entire body must 
be examined and the cause of the amenorrhea will be found 

General Causes. . it i r ji,i- n 

in general diseases much more frequently than is generally 
supposed. It must be remembered, however, that these diseases and 
nutritional disturbances are not the direct cause of the interruption of 
the process of menstruation. They merely produce atrophy of the 
ovaries, which is often followed by secondary atrophy of the uterus. 
Hence the local signs may be exactly the same in such cases as in amen- 
orrhea due to local causes (see above). In these cases also the severity 
of the process may be judged in part by the difference between concentric 
and eccentric atrophy. 

The following groups of diseases may cause amenorrhea : 

1. Infectious diseases which interfere with ovulation until 
far into convalescence. Amenorrhea is most frequent after typhoid 
fever and is also observed after cholera, scarlet fever, etc. 

2. Organic or general diseases due to chronic infection or 
other external injuries, such as pulmonary tuberculosis, syphilis, can- 
cerous cachexia, leukemia and nephritis. The woman's general health 
is weakened and she is injured in her most vital part, ovulation. 

3. A group of metabolic and constitutional diseases of 
obscure etiology also interfere with maturation of the follicles. They 
are diabetes, myxedema, acromegaly, exophthalmic goitre, Addison's 
disease, and chlorosis. 

4. Poisoning with drugs, or other substances taken in excessive 
quantities, such as morphin, opium, mercury, phenacetin (Olshausen) 
and alcohol. Amenorrhea following poisoning with arsenic and phos- 
phorus is probably local in character, due to destruction of the ovaries. 



ANALYTICAL DIAGNOSIS 619 

5. Severe psychic influences, such as friglit, violent excitement, 
or ps3'chic diseases, especially progressive paralysis. I have seen two 
cases belonging to this category. 

Case 44. Mrs. S., age 21. First menses at the age of 16; regular every four weeks, 
lasting three daj^s, scanty; last menses 15 months ago. Examination reveals a small uterus 
(length as determined by the sound, 5 cm.) and a small ovary on each side. The internal 
organs are normal and no physical cause of amenorrhea is given in the history. Tlie neurol- 
ogist's diagnosis of the patient's mentality is congenital imbecility, possibly 
with dementia praecox. 

Case 45. Mrs. W., age 44. First menstruation at the age of 20; regular every month, 
asting 4 to 5 days; last menses 8 months ago. Examination of the genitalia reveals a small 
uterus (length of cavity 6 cm.) and small ovaries. No internal cause can be found for the 
amenorrhea. The neurologist's examination of the mental condition reveals a severe 
melancholy which has been increasing for the past year. 

(It cannot be decided whether in each of the above groups, and par- 
ticularly in the case of the 1st and 2nd, the amenorrhea is due to organic 
diseases of the ovaries or merely to abolition of the follicular activity.) 

Aside from these conditions all kinds of causes which produce a 
temporary or permanent weakening of the body may arrest ovulation 
and thereby produce amenorrhea. These include anemia after severe 
hemorrhage, especially during parturition, which may also injure the 
uterine function directly. 

Case 46. Mrs. M., age 30 years. First menstruation at the age of 15; regular every 
four weeks, lasting 8 days; profuse. Married at the age of 17; has had four viable chil- 
dren, the last 8 years ago. Three years ago abortion, accompanied by profuse hemorrhage, 
after which she was confined to her bed for four months on account of persistent hemorrhages. 
After this menstruation recurred regularly fom- times, and since then there has been complete 
amenorrhea; molimina are absent. The internal organs show no cause for the amenorrhea. 
The uterus is 7 cm. long; the wall thinner than normal; both ovaries are of normal size. 

Long-continued and exhausting lactation may lead to amen- 
orrhea long after the child has been weaned ; also change of residence 
or occupation, when the change is an unfavorable one, from good 
hygienic surroundings to a debilitating mode of life, or the occupation 
is changed from physical work to which the woman is accustomed to 
severe mental exertion. The amenorrhea which is observed among 
young women training to become mid- wives belongs to this type; I 
have frequently observed this in Berlin in young girls from the country. 

Case 47. Mrs. N., age 20. First menstruation at the age of 13; regular. This is the 
third time the patient has had total amenorrhea immediately after coming to Berlin. The 
first time it lasted three months, the second time two months, and this time six weeks, while 
in her own home menstruation is always regular, although somewhat scanty. Molimina are 
absent. Examination shows that the uterine wall is attenuated; length of the cavity 7 cm.; 
both ovaries distinctly palpable. 

Amenorrhea occurring in women with urinary fistulae, the 
etiology of which is still obscure, and the amenorrhea which occasionally 



620 GYNECOLOGICAL DL\GNOSIS 

follows parturition in the absence of hemorrhage, infection or lac- 
tation also belong to this group. The association of general obesity 
with amenorrhea has never been explained. While on the one hand 
obesity develops in persons who are sterile, without any sexual desire 
and who gradually become amenorrheic, and is probably clue in these 
cases to insufficient oxidation resulting from the abolition of the ovarian 
function; there are also cases in which obesity is undoubtedly the 
primary disease, and if it is relieved, normal menstruation reappears. 
The above-mentioned conditions are positive causes of amenorrhea, 
and others will no doubt be discovered as our knowledge becomes more 
complete. Finally, it must be mentioned that in not a few cases the 
cause of amenorrhea cannot be discovered, and one must be content 
with the theory of a premature menopause. 



ANALYTICAL DIAGNOSIS 621 



The Causes of Dysmenorrhea. 

Definition. Dysmenorrhea signifies painful menstruation. It 
does not represent a disease nor a pathologic conception. It is merely 
a symptom and may occur in diseases of the genital organs, such as 
endometritis, myoma, diseases of the tubes. Accordingly 
the discussion of dysmenorrhea properly belongs to the 
symptomatology of these diseases, but I shall make the diagnosis of 
the causes of these symptoms the subject of a special chapter because 
it is often the only, or at least the most prominent, symptom com- 
plained of by the patient when she consults the physician. Another 
reason for doing so is that there are a number of separate forms of 
dysmenorrhea that are not characterized by definite and easily recog- 
nized physical signs, and depend on certain organic nervous changes 
which are difficult to detect. In daily practice the physician is tempted 
by the difficulty of recognizing these causes to content himself with a 
diagnosis of dysmenorrhea, but in giving such a diagnosis he is merely 
repeating under a high-sounding name the symptom which the patient 
has just described. 'Dysmenorrhea' as a diagnosis has no place in 
scientific gynecology, and it is the physician's duty to ferret out the 
anatomic or at least the functional changes which explain the 
painful course of the menstrual process. Unfortunately this is not 
always possible, and from this standpoint I consider the diagnosis 
of dysmenorrhea one of the most difficult problems presented in 
gynecologic diagnosis. 

It is important to remember in the first place that the menstrual 
process is not confined to the uterus and ovaries. All the organs con- 
tained in the true pelvis are more or less involved in the premenstrual 
congestion, and a number of more or less severe psychic changes take 
place in those organs which have a plentiful nerve supply, as the stom- 
ach, intestine, heart, and in the peripheral nerves of the head, because 
the central and peripheral nervous systems also take part in the process. 
Accordingly dysmenorrhea ought to include functional disturbaiices 
in remote organs and alterations of the psychic state; but the term 
is not generally used in that way, being limited to painful conditions of 
the pelvic organs. I shall therefore confine myself to the analysis of 
these conditions. 

Normal menstruation ought to run its course without any painful 
sensation beyond a feeling of heaviness in the abdominal organs and a 
slight painful pressure associated with a dragging sensation in the 



622 GYNECOLOGICAL DIAGNOSIS 

sacrum or to either side. Any painful sensation during menstruation 
is designated dysmenorrhea and must have a special cause. Pain is 
always a subjective symptom and individuals vary in their conception 
and toleration of it; hence women of good resistance may be barely 
conscious of dysmenorrhea, while delicate, sensitive persons suffer 
intense pain with the same objective changes. Nevertheless the degree 
of pain is the only criterion we have for the severity of the dysmen- 
orrhea. If a patient consults a physician on account of dysmenorrhea, 
it is a proof that the pain which she feels is too strong for her; 
hence a dysmenorrhea that induces a patient to consult a physician is 
always pathologic. 

In order to understand dysmenorrhea it is necessary to be familiar 

with the course of the menstrual process and the extent to which 

the various genital organs take part in it. Menstruation begins with 

maturation of the Graafian follicle in the ovary; the follicle 

The Normal '' ' 

Menstrual gradually fills up, reaches the surface and ruptures, and 

ProcGSS. 

this process, which is confined to the ovary, reflexly produces 
marked dilatation and engorgement of the vessels in the pelvic organs. 
The most marked effect is observed in the uterus; the uterine tissue 
becomes thicker and more rigid, and the entire organ lengthens out. The 
blood-vessels of the uterine mucosa become engorged; extravasations 
of blood into the upper layers of the greatly swollen mucous membrane 
take place and gradually cause separation of the epithelium, finally 
escaping as menstrual blood. The blood collects in moderate quantities 
in the uterine cavity and escapes through the cervix. The bleeding is 
accompanied by a decrease of the swelling, the epithelium regenerates, 
and in the course of a few days the mucosa regains its normal state. The 
tubes become thicker during menstruation by swelling of the mucous 
lining and, to a certain extent, of the muscularis. Rarely bleeding takes 
place into the lumen of the tube. The congestion also affects the ovaries 
and is probably the direct cause of the rupture of the follicles. The 
vagina, the pelvic peritoneum and, to a limited extent, the pelvic con- 
nective tissue also take part in the hyperemia. Menstrual congestion 
begins about eight or ten days before the flow, increasing gradually, 
and produces the most marked changes immediately before the blood 
begins to escape; it usually diminishes during the course of the bleeding 
and the vessels regain their normal vascularity soon after the flow has 
ceased. In order that the menstrual process shall run a painless course 
it is therefore necessary that nothing interfere with maturation and 
rupture of the follicles; that the congestion in the uterine wall do not 
meet with resistance from infiltration of the tissues; that the mucosa 
be capable of swelling and taking up the extravasated blood; that the 
size of the uterine cavity be sufficient to accommodate the swollen mucous 



ANALYTICAL DIAGNOSIS 623 

membrane; that the menstrual blood escape readily from the cervix; 
and that the congestion of the tubes and of the peritoneum take place 
in the normal tissues. In addition the nervous system must possess a 
normal degree of irritability and the psychic functions must be normal, 
otherwise the slight alterations which take place in the nervous system 
during normal menstruation may be abnormally exaggerated. 

Classification. It is obvious that the classification of dysmenorrhea 
must take account of the manner in which the various organs take part 
in the process. Accordingly we have ovarian, tubal, 

. . -, -, 1,11,,. Classification. 

uterine, and nervous dysmenorrhea; the last form 

finds its explanation solely in overexcitement of the nervous system 

without any objective changes. 

Although the peritoneum and parametrium also take part in the 
menstrual process, it is not necessary to make a separate classification 
of peritoneal and parame'trial dysmenorrhea, because the menstrual pain 
which has its origin in these structures is nothing more than an increase 
produced by the premenstrual congestion of pains due to adhesive and 
exudative chronic pelvic peritonitis, and parametritis with contraction. 
Women suffering from these diseases are rarely free from pain at any 
time, and if they suffer only at the time of menstruation, the dysmen- 
orrhea is so slight that they do not even consult a physician. Severe 
dysmenorrhea always originates in the organs themselves. 

A careful bimanual examination of the genital organs is necessary 
to determine the origin of this organic dysmenorrhea, which must have 
a definite objective cause. Simple ovarian dysmenorrhea is rare. It 
occurs in a mild form with chronic oophoritis as a ovarian 

dragging, stabbing, gnawing, boring pain or pressure in Dysmenorrhea, 
the region of the affected ovary, frequently radiating into the hips or 
legs. In most cases it is merely a menstrual exacerbation of the pain 
which is constantly present; but occasionally it is a pure dysmenorrhea. 
It usually appears a few days before menstruation. The cause of a 
pure ovarian dysmenorrhea is occasionally found in hemorrhages into 
the parenchyma of the ovaries, especially the follicles (haematoma 
ovarii). The ovaries appear greatly enlarged, rough on the surface, 
and occasionally attain the size of a child's head. Instead of a simple 
dysmenorrhea, constant pain, becoming aggravated during menstruation, 
may be present in these diseases. I have seen a well marked form of 
pure ovarian dysmenorrhea in cases of ovarian tumor with cpite recent 
torsion. The dysmenorrhea began shortly before the menstrual period, 
was always very severe, and manifested itself in cramp-like pains, chiefly 
confined to the affected side of the abdomen. These women sought 
relief merely for the dysmenorrhea and felt perfectly well during the 
intermenstrual interval. In every case I have found an ovarian tumor, 



624 GYNECOLOGICAL DIAGNOSIS 

usually a small one, with quite recent torsion of the pedicle and with 
adhesions. In some of the cases hemorrhages had taken place into the 
tumor. After extirpation the patients were relieved from their 
dysmenorrhea. 

Case 48. Mrs. St., 25 years old. First menstruation at the age of 17; always regular 
and painless; has been confined three times. For the past four months violent, boring, cramp- 
like pains in the left hypogastric region, appearing a week before menstruation and disappear- 
ing with the cessation of the flow; no intermenstrual symptoms. At the operation the uterus 
was found in retroversion, and on the left side a very movable ovarian tumor the size of a 
child's head', with a twisted pedicle and no adhesions. 

A positive diagnosis of ovarian dysmenorrhea always presupposes 
the presence of palpable changes in the ovary. The disease described 
by Olshausen as neuralgia of the ovary and dysmenorrhea occurring in 
cases of hypoplasia of the uterus, and attributed by Schauta to the 
changes in the ovary, are doubtful types of ovarian dysmenorrhea. 

Simple tubal dysmenorrhea is not uncommon and almost exclusively 
accompanies chronic salpingitis or its sequelge. In cases of recent 
inflammation the symptoms, which are quite severe before and during 
Tubal 'the period, are merely menstrual exaggerations of the pain 

Dysmenorrhea, -^yhich is coustautly prcscut; iu chrouic salpingitis the 
clinical picture is much more like that of dysmenorrhea. The pain is 
not characteristic and occurs chiefly before the periods; it is described 
as a dragging, sticking, stabbing or burning sensation in the side; it is 
therefore necessary for making a diagnosis of tubal dysmenorrhea to 
demonstrate distinct changes in the tube by palpation. In some cases 
the tubal pain is associated with true 'cramps'; these cramps as a rule 
do not originate in the tube, as that structure is no longer capable of 
active contraction, but are derived from the uterus which, without being 
itself diseased, reacts to the premenstrual congestion with labor pains. 

In chronic inflammatory conditions localized simultaneously in the 
uterus, adnexa, connective tissue and peritoneum, it is difficult to 
determine how much each organ participates in the process. The pre- 
menstrual congestion causes pain in various areas at the same time, and 
this form accordingly is also called congestive or inflammatory 
dysmenorrhea. 

From the standpoint of frequency and severity uterine dysmenorrhea 
is much more important than the forms so far described. Uterine pain 
is caused by contraction of the uterine muscle, known as labor pains. 
Uterine Since utcrinc contractions rarely occur when menstruation 

Dysmenorrhea, jg normal, aud the mild contractions of a healthy organ 
are not felt as pains if the nervous system is in good condition, there 
must be some abnormality which is the reflex cause of the painful con- 
tractions during dysmenorrhea. Pain occurs when the menstrual blood 



ANALYTICAL DIAGNOSIS 625 

accumulates in the uterine cavity in connection with inflammations of 
the endometrium and metritis, in imperfectly developed uteri with con- 
tracted cavities and contracted blood-vessels in response to the forcible 
stimulus of the menstrual wave; it may be reflex in the presence of 
hyperesthesia of the endometrium in irritable, nervous individuals, 
even when the menstrual process is anatomically normal. Painful 
contractions or uterine pains are common to all forms of uterine dys- 
menorrhea of whatsoever origin. Uterine dysmenorrhea may be due 
to a great many causes, the recognition of which is exceedingly difficult 
and by no means possible in every case. There are two methods of 
making a diagnosis and both are useful; they are examination and 
interrogation of the patient. 

By objective examination we first try to find out whether 
the uterus is the seat of the dysmenorrhea. This may be done by exclu- 
sion if the tubes and ovaries are healthy. It is difl&cult to find positive 
signs in the uterus because many cases of uterine dysmenorrhea are 
without any abnormal physical signs, e.g., all those which depend on 
endometritis and stenosis; on the other hand, the localization of the 
pain in the uterus is usually so definite as to dispel all doubt in regard 
to the seat of the dysmenorrhea. The patients often state that they 
feel the pain as jerky, rhythmical contractions resembling labor pains. 
Others describe it as a cramp-like sensation or pressure deep down in 
the middle of the pelvis, a feeling as though they had a 'stone' in the 
abdomen. Some women are less definite in their statements and com- 
plain of drawing pains in the sacrum radiating into both thighs; others 
again refer the uterine pain higher up into the abdomen around the 
umbilicus or under the arch of the ribs. After the uterine character of 
the dysmenorrhea has been established, objective changes may be found 
in some cases to explain the disease. Some of these changes are easily 
recognized, such as submucous myomata, acute-angled anteflexion and 
retroflexion in nulliparous women, chronic metritis, or well marked 
hypoplasia. These are exceptional, however; in most cases of uterine 
dysmenorrhea the palpatory findings are normal. Further information 
may be obtained by introducing the sound, which may reveal stenosis 
at the internal os or sensitiveness of the endometrium. 

From the history we learn, in addition to localization of the 
pain, whether the first attack of dysmenorrhea occurred either with the 
first menstruation or at some later period of the patient's life; whether 
the dysmenorrhea begins a few hours or a few days before the menstrual 
flow or follows the flow; whether it is present only during the first few 
hours or lasts several days and whether it recurs during the course of 
menstruation; whether the dysmenorrhea accompanies every men- 
struation or not and, if possible, the causes of its appearance or non- 
40 



626 GYNECOLOGICAL DIAGNOSIS 

appearance and its severity; the effect on dysmenorrhea of marriage, 
parturition, mode of life and occupation and of therapeutic measures. 
The information to be obtained by a careful interrogation of the patient 
may be exceedingly valuable to the experienced diagnostician. 

Mechanical dysmenorrhea occurrs when there is an obstruc- 
tion to the flow of menstrual blood with an accumulation of the blood 
in the uterine cavity, producing reflex contractions of the muscles which 
Mechanical cxpel the blood. If we adhere strictly to the definition of 

Dysmenorrhea, niechauical disturbaucc and exclude all those cases, espe- 
cially in ir"i-itable individuals, in which the presence of blood alone in the 
cavity produces reflex contractions, the mechanical form of dysmen- 
orrhea presupposes a stenosis of the cervical canal sufficient to prevent 
the passage of blood even in the finest stream. But since it is not prob- 
able that a normally formed uterus is ever the seat of a stenosis suf- 
ficient to prevent the passage of blood corpuscles, we must look for other 
contributory causes, such as the abnormally rapid secretion of large 
quantities of menstrual blood which cannot escape fast enough and, by 
accumulating in the cavity, produces reflex contractions; or the admix- 
ture of clots or particles of tissue which have difficulty in passing the 
inner os in nulliparous women. The last category includes many cases 
of exfoliative endometritis (dysmenorrhea membranacea) in 
which uterine contractions are produced by extrusion of the membranes. 
The most important factor in the production of a stenosis is the con- 
gestive swelling of the uterine mucous membrane, bringing the walls of 
the canal in close contact and effectually preventing the passage of blood; 
nevertheless it is necessarj'' to demonstrate that a stenosis is present 
before making a positive diagnosis of mechanical dysmenorrhea. Ste- 
noses at the external os are much easier to recognize than any others and 
usuallj" do not cause dj'smenorrhea. I have occasionally seen collections 
of menstrual blood behind the external os sufficient to cause actual 
ballooning of the cervix without the least pain. Stenoses of the internal 
os, which are much more important, are recognized by the inability to 
introduce a sound with a knob 2 mm. thick through the internal os. 
It must be borne in mind, however, that the sound merely recognizes 
narrowing of the cervical tissue, and readily forces its way through 
folds of mucous membrane that may be in contact with one another; 
hence the absence of obstruction to the sound at the internal os does 
not positively exclude stenosis due to swelling of the mucous membrane. 
Stenoses of the body of the uterus are rare. One indubitable case of 
this kind has, howcA'er, been reported by Olshausen, hence the 
possibility of corporeal stenosis must be borne in mind. 

A variable degree of anteflexion is very often found in the 
dj^smenorrhea of nulliparous women and virgins. This may undoubt- 



ANALYTICAL DIAGNOSIS 627 

edly produce stenosis of the uterine canal b)' angulation at the internal 
OS and, as the sound is apt to become arrested at this point unless the 
examiner has mastered the manipulations necessary for its introduction, 
the diagnosis of mechanical dj'smenorrhea appears to be justified. But 
this is b}' no means the case. A moderate degree of angulation is over- 
come by the extension and stiffening of the organ which takes place 
during menstruation, or the tissue around the internal os may be quite 
flaccid and offer no real obstacle to the escape of the menstrual blood. 
It is to be remembered also that an anteflexion may be combined with 
other conditions which are the true cause of dysmenorrhea; thus, a 
hypoplastic uterus is often anteflexed; in endometritis and posterior 
parametritis there may be a marked secondary anteflexion, and these 
conditions are the true causes of the dysmenorrhea. It is obvious also 
that nervous dysmenorrhea may occur with anteflexion. Hence, before 
a diagnosis of mechanical dysmenorrhea due to anteflexion can be 
made, these other much more frequent causes must be excluded; 
in other words, we must have in a person who is neither nervous 
nor hysterical a freely movable, normally developed uterus in permanent 
rigid anteflexion. 

In view of this uncertainty of the diagnosis of mechanical dysmen- 
orrhea it is essential to find some support in the history. As mechanical 
dysmenorrhea depends on congenital changes it occurs early, at least 
during the first years of sexual life, if not at the fiz'st menstruation. A 
characteristic feature is that the dysmenorrhea alwaj^s occurs not more 
than a few hours — never several days — before the menstrual flow, and 
that the pain almost always subsides as the flow becomes more abundant 
and does not return during menstruation unless the flow of blood is 
again arrested. This form of dysmenorrhea is but rarely influenced by 
regular coitus, while it usually disappears altogether after the birth of the 
first child. If dilatation with metal dilators proves permanently suc- 
cessful, it indicates that the d^'smenorrhea was due to mechanical causes. 
I have not infrequently seen a temporary benefit in endometritic dys- 
menorrhea also; but it is evident that this does not necessarily exclude 
a mechanical obstacle, since there is nothing to prevent its return after 
it has once been removed. 

A not infrequent form of dysmenorrhea is observed with imper- 
fect development of the uterus. Assuming that the ovarian 
function is normal, this form of dysmenorrhea may be 
explained by reflex contractions due to increased pressure ^Ui™mpe7f^ct 
in the uterine vessels, the increased pressure being due to i^eve'opment of 

' i " the Uterus. 

the fact that the vessels are too small to allow for the 
accumulation of blood, and the cavity too narrow to permit the necessary 
degree of swelling of the mucous membrane. Instead of a true men- 



628 GYNECOLOGICAL DIAGNOSIS 

struation there is merely a periodic congestion in the tissues, and the 
menstrual flow, at least in the beginning, is very scanty. The diagnosis 
is based chiefly on the abnormal uterus as recognized by palpation and 
the sound. Every grade from extreme hypoplasia to a merely under- 
sized virginal uterus, capable of conception and normal parturition, 
is seen in this form of dysmenorrhea, which often disappears after mar- 
riage or the first conception. Curiously enough its appearance is often 
delayed several years after the establishment of sexual maturity, as 
the menstrual congestion gradually becomes more profuse, and it is 
almost never felt after marriage. The bleeding is very scanty, beginning 
with only a few drops. The smaller the flow, the more severe the dys- 
menorrhea. The pain usually begins several days before the appearance 
of the blood, coincident with the beginning of the premenstrual con- 
gestion; increases steadily until the bleeding begins; and usually dimin- 
ishes when the flow has attained its normal strength, or ceases altogether. 
The pain may recur if the flow is interrupted. As deficient development 
of the genitaha is often part of a general underdevelopment associated 
with diminished bodily and nervous resistance, the latter is often a 
factor in the etiology of this form of dysmenorrhea. 

Another case of severe dysmenorrhea is found in inflammatory 
changes of the endometrium. The diagnosis of this endome- 
tritic dysmenorrhea, which is characterized anatomically in some cases 
Endometritic by iutcrstitial exudations, rarely by marked glandular 
Dysmenorrhea, chaugcs, is quite casy if thc dysmenorrhea is associated 
with menorrhagia; but in the simple forms of severe endometritic dys- 
menorrhea there is often a total absence of symptoms referable to the 
endometrium, such as leucorrhea and hemorrhage, and only occasionally 
nervous phenomena referable to the head and stomach. The diagnosis 
in such cases must be made solely by means of the sound (see p. 508). 
Irregularities are found at the fundus (endometritis fundi) and at 
the intersections of the tubes; the endometrium is extremely painful 
to the touch, particularly where the surface is uneven. The history and 
symptomatology are in many respects quite characteristic. Endome- 
tritic dysmenorrhea usually occurs from 8 to 10 days before the flow 
(coinciding with the beginning of the premenstrual congestion); 
occasionally the pain and the bleeding begin at the same time, and as a 
rule the dysmenorrhea continues during the entire period. The flow 
is normal and if anything increased in quantity, rarely diminished. As 
this form of dysmenorrhea is usually acquired it makes its appearance 
late; any dysmenorrhea beginning after marriage may, as a rule, be 
regarded as inflammatory. Nevertheless a dysmenorrhea which has 
existed since the first menstruation may be found in young women and 
often in virgins to be due to severe structural changes. Thus in the 



ANALYTICAL DIAGNOSIS 629 

case of a virgin the cause of dysmenorrhea was found in a severe 
endometritis which at each menstruation was accompanied by the 
exfoHation of thiclv pieces of membrane. Hence the fact that a 
dysmenorrhea began before marriage is no argument against its inflam- 
matory character. It is often difficult to decide whether it is primary 
or secondary, or both conditions are due to a common cause, such 
as masturbation. 

Besides this form of dysmenorrhea, which is due to inflammatory 
changes in the endometrium, there is another variety in which the same 
sensitiveness of the uterine mucous membrane is present without other 
nervous phenomena and without any demonstrable structural changes. 
The sound does not show any roughening of the surface, and in 
many cases the only objective change is a slight obstruction at the 
internal os caused by a fold of membrane which is exceedingly sensi- 
tive to the touch. The condition may be designated hyperesthesia 
of the endometrium. Theilhaber attributes it to spasm at the 
internal os. 

In one sense nervous dysmenorrhea also belongs to the 
uterine varieties because, in contradistinction to tubal and ovarian 
dysmenorrhea, it manifests itself in the uterus; but it differs very 
materially from genuine uterine dysmenorrhea by the fact Nervous 

that it is due to changes in the central nervous system and Dysmenorrhea, 
not to changes or abnormality of the uterus. In this form also the pain 
is caused by uterine contractions which, however, are not excited by 
any abnormality of the uterus but are rather the effects of unusual reflex 
excitability on the part of the uterine nerves and, owing to the morbid 
condition of the nervous system, are felt as painful sensations. This 
type of dysmenorrhea occurs in women with pronounced hysterical and 
neurasthenic symptoms, and also in the absence of such symptoms in 
excitable, so-called nervous individuals or in some whose nutrition is 
bad and who suffer from anemia or general debility. Accordingly this 
form usually occurs in city girls employed in industrial establishments, 
whose work is physically exhausting and who, in addition, overwork 
their brains; in girls who have been spoiled by their education both 
physically and mentally; and in childless women struggling under 
unhappy domestic conditions. The diagnosis of this very frequent form 
of dysmenorrhea is made by excluding all local abnormalities of the 
uterus that are known to be causes of dysmenorrhea, and by the presence 
of disease or weakness of the central nervous system. 

A special form of dysmenorrhea has been classified by Schiff and 
Fliess under the name of nasal dysmenorrhea. The pain is caused by 
painful contractions of the uterus excited by irritation of certain definite 
areas on the nasal mucous membrane, at the tuberculum septi and 



630 GYNECOLOGICAL DIAGNOSIS 

the anterior extremity of the inferior turbinate. Indeed it has been 
demonstrated beyond a doubt that this form of dysmenorrhea can be 
Nasal temporarily, and sometimes even permanently, cured by 

Dysmenorrhea, cocaiuizing and cauteriziug these areas. Nevertheless the 
effect of the treatment is open to various explanations. As yet the exist- 
ence of a simple nasal form of dysmenorrhea cannot be said to be proven. 
The following method may be pursued in the investigation of a 
case of dysmenorrhea. By interrogating the patient, the seat, duration 
and severity of the dysmenorrhea, the time of its first appearance and 
its relation to the menstrual flow, the effect of marriage, parturition and 
any local or general methods of treatment are ascertained. A local 
examination is then made, except in the case of virgins. If, however, 
both a nervous etiology and developmental disturbances can be definitely 
excluded, and a careful study of the patient's general 'constitution and 
the symptoms seem to indicate the presence of a mechanical obstacle, 
an examination is indispensable, particularly as local treatment will 
have to be applied. The examination should be made under anesthesia. 

The dysmenorrhea which is so extremely common in young girls may be due to a variety 
of causes. Insufficient development of the uterus and a slight stenosis at the internal os are 
the causes in some cases; while chlorosis and insufficient bodily development, associated 
with mental overexertion, are responsible for others. Hence these forms of dysmenorrhea are 
amenable to different kinds of treatment. 

By combined examination we determine whether the tubes and 
ovaries are the seat of changes capable of producing dj'^smenorrhea. 
If these organs are normal, or if the seat of the pain and its character 
at once point to the uterus as the seat of the dysmenorrhea, that organ 
should be subjected to careful scrutiny. First the degree of develop- 
ment is noted. If the uterus is of normal size and the width of the 
cavity, as determined with the sound, is found to be normal, hypoplasia 
may be excluded; while, on the other hand, a distinct diminution in 
the size suggests a dysmenorrhea due to arrested development. The 
sound is then introduced in order to search for any mechanical disturb- 
ance. The instrument must be handled very lightly, especially at the 
internal os, the width of which and any hyperesthesia of the mucous 
membrane must be carefully noted. If no objective changes are found, 
the corporeal mucous membrane is investigated for sensitiveness and 
inequalities. If the results of objective examination are absolutely 
negative, the nervous system is examined and the history completed 
by inquiring into the daily occupation, domestic surroundings, worries 
and the like. If neither the objective examination nor a careful study 
of the history clears up the case, some clue may be gained by observing 
the patient during treatment. One or two days before the beginning of 
menstruation the internal os is sounded or dilated; if this is not followed 



ANALYTICAL DIAGNOSIS 631 

by improvement, the presence of a mechanical obstacle may be definitely 
excluded from the diagnosis. If, on the other hand, the dysmenorrhea 
is relieved, the cause is probably mechanical. If the dilatation is fol- 
lowed by temporary improvement, the cause may still be found either 
in inflammation or developmental disturbances; for this type of dys- 
menorrhea is also susceptible of improvement by dilatation. In many 
cases the diagnosis cannot be cleared up until the patient has been 
under observation for some time. 



632 GYNECOLOGICAL DIAGNOSIS 



Causes of Sterility. 

Definition. Sterility is the inability of an individual to pro- 
duce progeny. Accordingly a man is called sterile when he is incapable 
of fertilizing a female ovum, and a woman when she cannot furnish an 
ovum that is capable of impregnation, or cannot bring a 
normal ovum to the seat where impregnation takes place, 
or cannot provide the necessary conditions for the further development 
of the impregnated ovum. But the physician who is called upon to 
determine the cause of sterility has to deal not with a sterile man or a 
sterile woman, but with a sterile marriage. While laymen usually apply 
the term sterility to a marriage that does not result in the production 
of hving or viable progeny, and accordingly include under the term 
sterility those cases in which the fetus is destroyed by habitual abortion, 
the physician must distinguish clearly between the two conditions, 
although the result in both is the same so far as the marriage is concerned; 
for in the latter all the conditions for a normal conception are present, 
while in the former they are absent. From the medical standpoint 
sterility is present when conception does not occur, or, if the ovum is 
impregnated, when it fails to become embedded. A marriage in which 
the ovum becomes impregnated and imbedded is not called sterile. 
Chnically it is difficult to distinguish between the two conditions, 
however, as habitual abortion may occur very early. 

It is equally difficult to name a time when a marriage may be 
regarded as sterile. Observations by Simpson show that it is exceptional 
for the first child to be born after the fourth year of marriage, and in a 
scientific sense a marriage may therefore be called sterile after that 
period. But the subsequent birth of a child is by no means impossible 
even if the sterility has not been specially treated. In actual practice, 
however, the observation has merely a prognostic value, as people lose 
patience long before the expiration of the four years and demand an 
answer to the question why their marriage continues childless. 

For practical purposes it is advisable to distinguish between 
absolute and relative sterility. The former is a condition in 
which pregnancy is absolutely impossible as in the case of a rudimentary 
uterus; while relative sterihty refers to conditions which only interfere 
with the act of conception, such as a stenosis at the external os. A 
distinction between primary and secondary sterility is also of 
diagnostic value. A marriage is called primarily sterile when pregnancy 
does not take place at all, while in secondary sterility the birth of the 



ANALYTICAL DIAGNOSIS 633 

first child is not followed by subsequent pregnancies because one of the 
parents becomes diseased. 

The general practitioner is quite often called upon to determine the 
cause of sterility. As a rule the husband sends his wife for examination 
because he takes it for granted that she must be the cause of the sterility, 
or the wife comes of her own accord under the same impression and in 
the desire to remove any obstruction to conjugal happiness. The phy- 
sician is thus easily tempted to devote his attention chiefly to the wife 
and to neglect the husband, a practice which is quite erroneous, as our 
views on this question have undergone considerable modification to 
the disadvantage of the husband. 

By examination of the semen it has been shown that the husband may be respon- 
sible for the sterility. We recognize several abnormal conditions. In azoospermia 
the semen ejaculated during coitus is entirely devoid of spermatozoa. In oligosper- 
m i a the semen contains only a few spermatozoa with diminished motility (although 
theoretically conception is possible under these circumstances, there is practically no dif- 
ference between azoospermia and oligospermia). Finally, there is a third condition, so-called 
necrospermia, in which the semen contains normal spermatozoa almost or quite incap- 
able of movement. How this condition is responsible for sterility is not very well understood. 

The following table shows to what extent the male may be responsible for a sterile marriage. 

Kehrer: Among 96 cases azoospermia was found in 30 per cent., oligospermia in 11 per cent. 

Lier ^ 

and [ " 132 " " " " " 32 per cent. 

Ascher ) 

Schenk " 110 " " " " "33 per cent., " " 12 per cent. 

Knorr " 72 " " " " " 25 per cent., " " 25 per cent. 

The results of these investigators, which are fairly uniform, indicate that the male is the 
true cause of sterility in one-fourth to one-third or, if the cases of oligospermia are included, 
in almost one-half of all the cases. 

These facts have caused a complete revolution in our views as to 
the causes of sterility, and it is therefore absolutely necessary to examine 
both husband and wife. Whether we begin with the one or the other 
is in the main immaterial; but as examination of the semen is much 
simpler, while in the case of a woman a diagnosis of sterility is much 
more difficult and sometimes requires general anesthesia, it is more 
logical to begin with the husband. At all events it should first of all 
be ascertained whether he is capable of begetting children, before the 
woman is subjected to a course of treatment. 

Examination of tlie Husband. This must include an investiga- 
tion as to his power of performing the sexual act and of impregnating 
the ovum (potentia coeundi et generandi). Since this chapter 
is devoted to sterility in the female, I shall not go into the causes of the 
former nor describe in detail the pathologic changes that have been 
found in the semen, which will be found in special textbooks on the 
subject by Ziilzer, Oberlander and Fiirbringer. A word of advice in 



634 GYNECOLOGICAL DLIGNOSIS 

regard to the method of obtaining the semen may not be amiss, how- 
ever. The specimen to be examined must have been ejaculated regularly 
during coitus. Semen obtained from an involuntary discharge that has 
dried on the clothing is absolutely valueless; compression of the seminal 
vesicles by introducing a finger into the rectum, a method frequently 
practiced by genito-urinar}' surgeons, does not always yield a sufficient 
quantity of semen; and the material obtained by masturbation may, 
in the case of an inexperienced individual, consist of nothing but pros- 
tatic fluid. The semen ejaculated during sexual congress should be 
received in a rubber condom, or withdrawal may be practiced and the 
semen discharged into a test-tube. The specimen must be examined 
under the microscope within an hour after coitus and kept at body- 
temperature during the interval. 

Examination of the Wife. The search for a cause of sterility 
somewhere in the body is much more complicated in the case of a woman 
because it may reside in any portion of the genital organs, or in the 
organism as a whole and particularly in the nervous system, inasmuch 
as any disturbance of the genital functions may be due to nervous or 
general causes. 

The sole function of the female genitalia is impregnation of the 
ovum, its subsequent nutrition, and expulsion of the fully developed 
product of conception. Each individual organ plays its special part in 
this function. Sterility occurs when any one of the organs becomes 
useless for the purposes of conception. Hence sterility is not an inde- 
pendent pathologic condition, but a symptom of various genital diseases. 
The physician must determine what organ is primarih' responsible for 
the sterility and also the disease which is the direct cause. The diag- 
nosis must therefore take account of all the organs concerned in con- 
ception, although, as their comparative importance is different and the 
diseases to which they are subject vary in frequency, they are not all 
of equal diagnostic significance. 

As a foundation for the functional examination of the individual 
genital organs the physician must possess an accurate knowledge of 
the mechanism of conception, and I am therefore compelled to begin 
Mechanism witli its clcscription SO far as it applies to the woman, 

of Conception. Couceptiou presupposcs a normal coitus, in which the 
semen containing viable spermatozoa is deposited in the upper portion 
of the vagina. If the os is open, the semen may be directly injected into 
the lower portion of the cervix; but this is b}' no means essential. The 
entrance of the spermatozoa into the external os, which usuall}' dips into 
the seminal lake, is effected chiefly by the motility of the spermatozoa. 
The livelier they are, the more readil}^ they effect an entrance. If they 
are retained too long in the vaginal vault, the functional power of the 



ANALYTICAL DIAGNOSIS 635 

spermatozoa is diminished because the acid of the vaginal secretion 
paralyzes and ultimately abolishes their motility. It has never been 
positivel)^ determined whether the semen is aspirated into the cervix 
after the mucous secretion of the canal has been expelled by the uterine 
contractions. As soon as the spermatozoa have entered the cervical 
canal they travel upward along the wall of the cervix, pass through the 
external os into the uterine cavity, and meet the ovum. The meeting 
point of semen and ovum has not been definitely determined, but most 
investigators agree that the meeting takes place in the tube and possibly 
in the abdominal extremity. If that is the case, the spermatozoa have 
a long distance to travel and must be possessed of active and prolonged 
motility; the life of the spermatozoa is probably from 6 to 8 days. A 
second prerequisite for conception is that an ovum capable of being 
impregnated shall arrive at the point where conception takes place. 
The ovum matures in the Graafian follicle of the ovary; just how an 
ovum must be constituted for purposes of conception, and whether 
there are ova which are naturally incapable of being impregnated, we 
do not know. The follicle grows by a gradual accumulation of fluid, 
reaches the surface of the ovary, and ruptures. This process takes place 
during the premenstrual congestion, probably a few days before men- 
struation. After the follicle has ruptured, the ovum with the follicular 
fluid is expelled into the abdominal cavity and must be taken up by 
the fimbriated extremity of the tube. The nearer the fimbrise are to 
the ovary, the more readily they take up the ovum. It is very improb- 
able that the abdominal extremity of the tube swells up and undergoes 
erection, or actually grasps the ovary during this process. From the 
position of the ovarian fimbria it is evident that the ovum can 
follow this path only in exceptional instances. In its short passage 
from the point where the follicle ruptures to the nearest border of the 
fimbrise the ovum is very probably assisted by a current which is set 
up by the movement of the ciliated epithelium in the tubes, in a direction 
toward the lumen of the tube. As soon as the ovum has been taken 
up by the tube it is easily retained among the folds and carried onward 
toward the uterus by the ciliated epithelium, until it meets the sper- 
matozoon. Contraction in the muscular wall of the tube for the purpose 
of carrying the ovum onward, if it occurs at all, is possible only in the 
uterine portion, where it may be necessary for the onward movement 
of the ovum after it has become impregnated. If the ovum fails to 
enter the tube it is destroyed in the abdominal cavity. The ovum begins 
to undergo the first changes, which result in its becoming embedded 
in the uterus by means of the villi of the ectoderm. This is the beginning 
of pregnancy. To what extent the nervous system and the psj^chic 
functions take part in conception is difficult to say, but it is very 



636 GYNECOLOGICAL DIAGNOSIS 

probable that the normal voluptuous sensation experienced by the 
woman facilitates conception. 

Conception accordingly presupposes the functional integrity of all 
the genital organs and the action of various mechanisms. Many differ- 
ent disturbances may therefore produce sterility, and the diagnosis of 
its causes requires a ver}' thorough examination. The history is of 
secondary importance, although occasionally the statements of the 
patient may at once reveal the cause of the sterility (see later). In 
making an objective examination the function of each individual organ 
must be constantly kept in mind, and examination must determine 
whether the organ is capable of performing this function. 

We begin with the external genitalia, whose function during 
conception consists solely in permiting the penis to enter the vagina. 
The causes of sterility in this respect may be adhesions of the vulva due 
External ^'^ malformations or ulcerative processes; large neoplasms 

Genitalia. wliicli prcvcut the approach of the penis, such as large 

lipomata. elephantiasis, or abnormally long labia minora and clitoris. 
The act may also be diffictilt if the vulva is situated abnormally far 
backward. Caruncles around the external uretkral orifice ma}' be so 
sensitive as to forbid the approach of the penis. Certain changes in 
the external genitalia (see p. 549) are of importance because they arouse 
the suspicion of hermaphroditism, which explains the apparent sterility. 
With regard to these abnormalities of the vulva, it is to be remembered 
that actual penetration of the penis into the vagina is not necessary 
for impregnation, as the spermatozoa may be sufficiently active to make 
their way into the vagina and uterus when they are deposited on the 
outside of the genitalia. Hence, if the vulva is not completely occluded, 
and the semen can be deposited in front of the introitus, there is a possi- 
bility of conception taking place. Catarrhal conditions at the vestibtile 
interfere with coitus because they cause pain, and in craurosis vulvie 
the contraction of the vestibule is sometimes so great that the penis 
cannot be introduced. 

The causes of sterility that are operative at the introitus in the 
main aft'ect the permeabilitj' of the passage and render conception 
difficult without, however, preventing it altogether. The hymen . which 
Introitus may resist attempts at cohabitation for some time, prevents 

\agins-. ^YiQ entrance of the penis unless it is very much distended, 

but does not render conception impossible because the spermatozoa are 
capable of passing through the hymeneal opening and reaching the uterus 
even if the penis is not introduced. There have been numerous cases 
of pregnancy with an intact hymen and when the opening in the mem- 
brane was extremely small. Atresia of the hymen is of course an 
absolute bar to coitus. A more serious obstacle to conception is pre- 



ANALYTICAL DIAGNOSIS 637 

sented by vaginism because the extreme sensitiveness at the introitus 
does not permit the approach of the glans, and the introitus is closed by 
spasmodic contractions of the constrictor cunni. In every day practice 
vaginism is quite a frequent obstacle to conception, although it does 
not render it absolutely impossible. The diagnosis is based on extreme 
sensitiveness at the introitus, the presence of hymeneal remains, and 
the occurrence of reflex spasms of the muscles around the introitus and 
in the floor of the pelvis following the slightest irritation of these areas- 
In certain aberrant cases of vaginism the parts are not in the least sensi- 
tive to the touch and the width of the introitus is normal; but when- 
ever cohabitation is attempted, the constrictor cunni and levator ani 
muscles contract and prevent the introduction of the penis. The cause 
in these cases is psychic. 

In a case of this kind, in which dilatation had been performed without benefit by another 
physician, I effected a cure by having the husband, who was a doctor, administer an injection of 
morphin immediately before cohabitation. This had the effect of preventing the muscular con- 
tractions, the act was performed in the normal manner, and in a short time pregnancy occurred. 

Abnormal width of the introitus, which is present in cases of 
prolapse and old perineal tears, frequently interferes with conception 
because the seminal fluid escapes from the vagina immediately after 
the sexual act. 

The function of the vagina is to receive the penis during the sexual 
act so that the semen may be deposited in front of the vaginal portion 
of the cervix, and to retain it there until the spermatozoa have entered 
the uterus. Hence total absence of the vagina, 
which is usually associated with severe developmental 
disturbances of the uterus, is obviously a cause of sterility. In such 
cases coitus usually takes place through the urethra or rectum, and 
pregnancies have been observed in cases in which the lower portion of 
the vagina was completely occluded and there existed a rectovaginal 
or vesicovaginal communication. In cases of double vagina sterility 
is observed when the sexual act has been performed in the half which 
is occluded. In order to perform its function the vagina must be patu- 
lous as far as the vaginal portion; hence cicatricial stenosis of the vaginal 
wall, like the so-called circular stenoses, interferes with conception, 
but, as in the case of intact hymen, does not necessarily prevent it 
altogether. Occlusion of course is an absolute bar to conception. Large, 
projecting cysts of the vaginal wall also interfere with the introduction 
of the penis. Adhesive fleshy bands running from the vaginal portion 
to the vaginal wall prevent the entrance of the seminal fluid. Stenosis 
of the vagina followed by sterility may also be due to tumors of the 
wall, such as carcinoma and sarcoma, or tumors pressing on the lumen 
of the vagina from without, particularly when they are situated in 



638 GYNECOLOGICAL DL\GNOSIS 

Douglas' space. Downward displacement of the vagina and prolapse 
do not always cause sterility because they are replaced during the act 
of cohabitation. The vagina must also be wide enough to receive the 
penis, and of the necessary length, else the glans will enter one of the 
vaginal vaults and deposit the semen there. As a rule, however, differ- 
ences of this kind in the dimensions of the genitalia are equalized during 
normal cohabitation. An abnormally short vagina is an obstacle 
to conception because the spermatic fluid is apt to escape, while an 
abnormally wide and relaxed vagina has the same disadvantage, 
especially if the iulroitus is very wide and there are ohl perineal lacera- 
tions, or reflex contraction of the constrictor cunni and levator ani 
muscles, the object of which is to retain the semen, fails to take place. 
Escape of the semen is a frequent cause of sterility and usuall}' points 
to abnormalities of the vagina. ^" a g i n a 1 c a t a r r h sometimes prevents 
conception because the spermatozoa are washed out of the canal with 
the secretions and because the hyperacidity of the vaginal secretion 
weakens the vitality of the spermatozoa. Patients with vesicovaginal 
fistula* are usually sterile, partly because the acid urine kills the sper- 
matozoa and washes them away, and partly because these patients 
usually suffer from amenorrhea. 

The vaginal portion probabl)' has no other function during con- 
ception than to dip into the seminal lake in the vaginal vault and thereb}^ 
facilitate the entrance of the spermatozoa into the uterus. Never- 
y^jj-^j^i theless any abnormality in its position relative to the axis of 

Portion. 1^1^^, vagina, its shape and the width of the external os, may 

interfere with conception. The most favorable position is that in which 
the vaginal portion forms a right angle with the vagina and lies exactly 
in the median line, with the os directetl accurately backward and down- 
ward (^in other words the normal position of the cervix), because in that 
position the penis, entering from in front and above, deposits the semen 
immediately in front of the external os. Any deviation from this posi- 
tion interferes more or less with conception but does not render it 
impossible. Changes in the shape of the vaginal portion not infrequently 
cause sterility. Elongation of the portio, such as infravaginal or penis- 
shaiKHl hypertrophy, elongation of one lip in the form of an apron with 
displacement of the os to the opposite side, follicular hypertrophy, or 
a long conical vaginal portion may interfere with conception in the 
absence of any other complication, because the penis glides by the 
vaginal portion and deposits the seminal fluid in the vaginal vault. 
Shortening and absence of the vaginal portion are often found in sterile 
women. The}' are, however, not in themselves the cause of sterility, 
but indicate a coexisting atroph}' of the uterus. Stenosis of the 
external os is an important condition. Before the technique of 



i 



ANALYTICAT> DIAGNOSIS 030 

bimanual cxaniination was dovflopfl arifl diseases of i,)\<; tubes anr] 
peritonoum were not recognized, these stenoses were usually regarded 
as the cause of sterility. Occlusion of the external os is of course an 
absolute bar to conception; but simple stenosis plays a variable part 
in the causation of sterility in different cases. The spermatozoa do not 
need much room, and pregnancy is therefore occasionally observed 
when the os is so narrow that only the smallest sound can be introduced. 
It should also be mentionerl that congenital stenosis of the external 
os, with a long, conical cervix, is associated with atrophy of the uterus; 
the cervical canal behind the contracted os is frequently the seat of 
catarrh, and the inspissated secretion prevents the entrance of the 
spermatozoa. Hence these disturbances, which are much more import- 
ant causes of sterility, must be excluded before the condition can be 
attributed to stenosis of the external os alone. Sometimes this requires 
a dilatation. In the main it is advisable not to lay too rn ach stress on 
this form of stenosis; at least it should never prevent a careful exami- 
nation of the higher portions of the genitalia. With regard to congenital 
stenosis of the external os resulting from plastic operations or ulcerative 
processes, their significance must not be overestimated as they are 
not an absolute bar to conception. The same is true of stenosis due to 
carcinoma or myoma. The diagnosis of stenosis presents no difficulties. 
The OS is exposed in a Simon speculum and the patulence of the canal 
determined by introducing a sound. 

In order to play its important part in conception the cervix must 
be patulous and permit the entrance of a viable semen into the uterine 
cavity. Hence disturbances referable to the cervix are always of a 
purely mechanical nature. It is needless to say that com- 
plete occlusion is an absolute bar to conception. The 
diagnosis is made with ili'' sound and sometimes by the presence of 
hernatometra, which is regularly present in sexually mature women. 
Without hernatometra complete occlusion is very improbable. It is 
much more difficult to decide what part stenosis of the cervix plays 
in the production of sterility. In the first place, it is not easy to diag- 
nose a stenosis, because the sound is very apt to catch in the recesses 
and folds of the normal cervix and because, as has been mentioned in 
connection with dysmenorrhea, the lumen may be obstructed by folds 
of mucous membrane which yield to the passage of the sound, so that 
the stenosis is overlooked. Various malpositions of the uterus, such as 
anteflexion and retroflexion, produce apparent stenosis by kinking of 
the cervical canal. True steriosis may be said to exist when a sound 
about 2 mm. in thickness cannot be made to pass a certain point even 
when the vaginal portion is drawn down with a tenaculum. The site 
of predilection is the external os; but stenoses also occur in the course 



640 GYNECOLOGICAL DIAGNOSIS 

of the canal, particularly as a result of malignant processes. As in the 
case of the external os, stenosis of the cervix is not an absolute bar to 
conception, but merely renders the act more difficult. In many cases 
it is not the only cause of sterility, which is due rather to the same cause 
as the stenosis itself, namely catarrhal diseases of the mucous membrane, 
and to its results, especially the accumulation of secretions in the cer- 
vical canal. While too much importance has no doubt been attached to 
stenosis of the cervix as a cause of sterility, it cannot be denied alto- 
gether, as cases in which pregnancy follows a single dilatation are not 
very infrequent. If a stenosis is definitely recognized it should be 
regarded as the cause of the sterility and subjected to treatment. 
Tumors of the cervix also act chiefly as mechanical obstacles; myoma 
causes displacements and contractions of the cavity, mucous polyps 
may obstruct it altogether. Carcinoma causes contraction of the canal 
in the earl}^ stage and later may produce dilatation, while the decom- 
posing secretions kill the spermatozoa or flush them out of the canal. 
Elongation of the cervix accompanying prolapse is another 
cause. Severe cervical catarrh is not infrequently associated 
with sterility, partly because the inspissated secretions obstruct the 
cervical canal, especially when thej^ accumulate behind the external os 
in nulhparous women ; and partlj^ because they wash the spermatozoa 
away, especially in cases of purulent catarrh, in which the chemical 
composition of the secretion is changed. 

In the body of the uterus, which performs several functions 
during the act of conception, a variety of functional disturbances may 
cause sterility. In the first place the uterine body affords the sper- 
Bodyof matozoa access to the ovum within the tube and retains 

the Uterus. ^|-^g impregnated ovum. The integrity of the spermatozoa 
must be maintained until impregnation takes place. The chief function 
of the uterus, however, is to permit the impregnated ovum to become 
embedded within its cavity. 

The first requisite, therefore, is the presence of a uterus capable of 
performing its function; any marked malformations, such as a 
rudimentary uterus without a cavity, or a fetal uterus with elongated 
cervix and short body, cause steriUty. An infantile uterus and marked 
degrees of hypoplasia are also, as a rule, accompanied by sterility; but 
it is difficult to decide whether the uterus itself or the atrophy of the 
ovaries, which is also present, is the chief cause. Menstruation may 
help to clear up the question. If it is absent or the flow is abnormally 
feeble, sterility is almost regularly present also. Acquired atrophy, 
whether due to disease of the uterus or to general conditions, is some- 
what uncertain in its relation to sterility; as a rule the character of 
the menstruation will reveal the cause of the sterility. If menstruation 



ANALYTICAT. DIAGNOSIS 641 

is absent, these atrophies usually lead to sterility; although many 
exceptions are observed, e.g., conception during the amenorrhea of 
lactation and during convalescence from severe diseases. Concentric 
atrophy is a much more certain cause of sterility than eccentric. 
Double malformations of the uterus do not, as a rule, lead to 
sterility, provided the function is completely preserved in one half. 
Total or partial atresia or stenosis of the uterine cavity, 
which may follow severe puerperal disease, cauterization or curet- 
tage, constitute purely mechanical obstacles. The diagnosis is based 
on the finding of a stenosis with the sound and the presence of hema- 
tometra whenever the mucous membrane is capable of functionating. 
With regard to displacements of the uterus as a cause of sterility, 
cases complicated by catarrh of the uterine mucous membrane, chronic 
pelvic peritonitis and diseases of the adnexa must be excluded. There 
are two ways in which a malposition may prevent or interfere with 
conception: abnormal position of the vaginal portion in the vagina, 
and angulation at the internal os due to flexion. Marked degrees of 
lateroversion and lateroposition very often cause sterility because the 
penis deposits the semen in the vaginal vault, which is in the median 
line and not in front of the more laterally situated external os. In the 
same manner in marked degrees of retroflexion access to the external 
OS may be difficult because it is placed far forward. In retroversion 
and in anteflexion the vaginal portion is more favorably situaterl for 
the reception of the spermatozoa. Prolapse is not so apt to form an 
obstacle because it is often corrected during the sexual act.' Flexion 
with contraction of the internal os may or may not be the cause of the 
existing sterility. In multipara; it is hardly worth mentioning, although 
retroflexion in multipara; may interfere somewhat with conception. 
With nulliparous women the case is different. Sterility often accom- 
panies anteflexion, but the anteflexion is not always the cause of the 
condition. If we omit cases in which the anteflexion is secondary to 
posterior parametritis, or merely represents a minor feature of insuffi- 
cient development of the uterus, and consider only those in which the 
anteflexion is congenital and uncomplicated, displacements are very 
unimportant as a cause of sterility and at most interfere with conception 
by causing angulation at the internal os. The same applies to uncom- 
plicated retroflexion in nulliparous women in whom the already exist- 
ing contraction of the canal becomes accentuated. In complicated 
cases the etiologic significance of displacements can only be determined 
by observation or by noting the results of treatment, particularly 
dilatation of the cervix. 

The only neoplasms of any significance as causes of sterility 
are the my o mat a, which operate by obstructing and narrowing the 

41 



642 GYNECOLOGICAL DIAGNOSIS 

uterine cavity and thereby preventing the semen from reaching the 
ovum, or through the profuse secretion of the uterine mucous membrane 
and endometritis which they also produce. As these conditions are 
always present in cases of submucous myoma, that variety of tumor 
is the most common cause of sterility. These generally accepted views 
have been shaken and in part refuted by Hofmeier, who has shown that 
in many cases myomata probably facilitate instead of preventing con- 
ception. Carcinoma is rarely a cause of sterility because it usually 
occurs in senile women or in women whose fertility is on the wane. 
Like sarcoma it undoubtedly interferes with conception. 

From a practical standpoint the most important cause of sterility 
in the uterine cavity is endometritis, because the abnormal secre- 
tions which it produces prevent the entrance of the spermatozoa and 
flush the ovum out of the cavity, because the smooth, atrophic mem- 
brane is unable to retain the ovum, and finally because of the difficulty 
or impossibility of the endometrium's being converted into a decidua. 
If in addition it is remembered that endometritis is an important cause 
of habitual abortion, it is evident that this disease is by far the most 
frequent cause of childless marriages. The various forms of endometritis 
are not of equal etiologic importance. Conception is sometimes observed 
in the presence of chronic hyperplastic inflammation associated with 
severe hemorrhage, more rarely in catarrhal, and most rarely in dysmen- 
orrheal and exfoliative endometritis. The sterility which so often accom- 
panies chronic metritis is usually due to a complicating endometritis. 
The question whether the tubes are responsible for the sterility 
is comparatively simple because the part which they play in conception 
is also a simple one. It consists in the reception of the ovum; its expedi- 
tion, whether impregnated or not, into the uterine cavity; 
and its maintenance during that time in a viable condition 
so that it may become impregnated or develop into a fetus. The recep- 
tion of the ovum presupposes patulence of the fimbriated extremity. 
Diseases which produce closure of the tubes are an absolute bar 
to conception. Occlusion is diagnosed by its sequelae or so-called reten- 
tion tumors — pyosalpinx, hydrosalpinx and hematosalpinx; occlusion 
probably exists also in severe salpingitis of any kind, particularly when 
there are adhesions in the neighborhood of the abdominal extremity 
of the tube. The orifice of the tube must furthermore be situated near 
the ovary. It is not possible to determine the position of the normal 
infundibulum; but if there is local pelvic peritonitis in its neighbor- 
hood, the structure is very probably fixed. After the ovum has entered 
the tube it is retained by the folds of mucous membrane and swept 
along by the movement of the cilia, provided the mucous membrane is 
normal. For this reason endosalpinx in itself is an obstacle to con- 



ANALYTICAL DIAGNOSIS 643 

ception and, in addition, when the infundibulum is open, the ovum may 
be washed out by the secretions, or the organisms which they contain 
may dcstro}' the ovum. If the infiltration involves the wall of the tube, 
the latter becomes rigid and no longer capable of muscular contraction 
for the purpose of pushing the ovum onward. Hence salpingitis 
interferes with conception in a variety of ways and in its various stages 
no doubt represents the most frequent cause of sterility. Whenever 
distinct thickening of the tube is present it may usually be regarded 
as the cause of the sterility, although it must be admitted that 
mild degrees of inflammation may subside without abolishing the 
function of the tube. 

The function of the ovary in the act of conception consists in 
maturation of the ovum and its discharge into the tube. The details 
as well as the disturbances of the process of ovulation are entirely be- 
yond our ken. Clinically they are manifested in atrophy 
of the ovaries and may be recognized by two signs — dim- 
inution in the size of the ovaries and cessation of menstruation. So 
long as menstruation continues it is very probable that mature ova 
are being produced. If it ceases, however, and the ovaries are small, 
ovulation must be regarded as abolished or at least impaired; hence the 
association of these two signs is directly in favor of ovarian sterility. 
The physiologic type of the latter is found in the menopause. The 
pathologic causes of deficient ovulation are congenital hypoplasia 
of the ovaries; atrophy due to diseases and other conditions (see 
Amenorrhea, p. 618); acute and chronic oophoritis, which also 
interferes with ovulation, with maturation of the ovum, with the forma- 
tion of follicles, and renders conception improbable. The extrusion of 
the ovum from the ovary necessitates a slight rupture of the follicle; 
hence thickening of the ovarian stroma as in chronic oophoritis, the 
deposition of peritonitic exudate, the formation of peritoneal adhesions, 
and the formation of peritoneal cysts on the ovary which is included in 
the term perioophoritis, interfere with conception and may pro- 
duce complete sterility. As regards ovarian tumors, it may be 
stated in general that so long as any ovarian tissue capable of function- 
ating remains, conception is still possible; hence a unilateral tumor 
does not directly affect conception, although it may be an indirect 
cause by displacing the uterus, vagina and adnexa. Even in the case 
of bilateral ovarian tumors conception is possible so long as function- 
ating 'ovarian tissue is present, which again may be determined by the 
behavior of menstruation. Sterility is observed most frequently with 
bilateral, malignant ovarian tumors. 

The last organs which must be included in the examination are the 
pelvic peritoneum and the connective tissue. 



644 GYNECOLOGICAL DL\GNOSIS 

Pelvic peritonitis plays a very prominent part in the etiology of 
sterility. Aside from cases in which the pain is so severe as to prevent 
normal coitus and cases in which conception is out of the question on 
Pelvic account of the presence of large exudates which displace 

Peritoneum. ^^iB utcrus and Completely surround the organs, especially 
the tubes — cases in which the sterility rarely comes up for diagnosis — 
chronic pelvic peritonitis with adhesions for a variety of reasons is the 
most common cause of sterility. The uterus itself may retain its function 
even when it is completely surrounded and fixed by adhesions. Adhe- 
sions are therefore less important than perisalpingitic and peri- 
oophoritic processes. Adhesions may completely surround the tube 
and cause contraction or angulation of the canal; or the infundibulum, 
which is the most common starting point of pelvic peritonitis due to 
tubal disease, may become fixed at some distance from the ovary; 
or the lumen may be occluded by adhesions. Not infrequently the 
portion of the peritoneum between the tube and the ovary, along which 
the ovum travels during its passage to the tube, becomes rough as a 
result of inflammation, or covered with adhesions. On the other hand, 
peritonitis may produce the above-described changes in the ovary; 
in short, chronic pelvic peritonitis interferes more with the process of 
conception and more often destroys the function permanently than 
any other disease. In many of these cases the complicating tubal diseases 
alone interfere with conception. 

Parametritic processes play a minor part in the etiology of sterility 
because they are extraperitoneal and do not impair the functions of 
the organs. Sterility is observed, however, in cases of large parame- 
tritic exudates on account of the marked displacement of 
the organs and the interference with the nutrition of the 
entire body; the same is also true of extensive parametritis with atrophy. 
The circumscribed retracting (posterior) forms occasionally produce 
sterility by displacing the uterus and ovaries. 

In the manner just described we must look for some organic change 
capable of disturbing the process of conception. As many of these 
causes consist in minute changes of the peritoneum and of the tube 
which can be felt only under especially favorable circumstances, it is 
advisable always to examine under anesthesia unless very conspicuous 
changes point to the correct diagnosis. If after a careful examination 
under anesthesia no change in the organs of generation capable of 
producing sterility is found, we must turn our attention to two other 
possible factors — the general condition and the presence of disturbances 
in the nervous functions which are necessary for conception to take place. 

Thus nutritional disturbances affecting the entire organism may 
produce sterility by causing atrophy of the uterus or interfering with 



ANALYTICAL DL4GNOSIS 645 

maturation of the ovum; whether both of these conditions develop at the 
same time or one is secondary to the other cannot be determined 
in everj^ instance. As the ovarian function is in the great majority 
of cases chiefly affected by conditions causing emaciation or other change 
in the body, the causes of this class usually lead to both amenorrhea 
and sterility. Hence the general causes of amenorrhea detailed on 
page 618 must be taken into consideration with respect to sterility 
also; they need not be repeated in this place. We knew from experi- 
ence, however, that amenorrhea and sterihty do not always go hand 
in hand and that conception during amenorrhea is not such a very rare 
occurrence. The ovarian function may not be entirely abolished; it 
may be only that the ovarian stimulus is not sufficient to produce a 
menstrual congestion, or the uterine atrophy is so great as to render 
menstrual bleeding impossible. Conception during amenorrhea is 
observed frequently in cases of atrophy clue to lactation, in the amen- 
orrhea accompanying convalescence from severe diseases, and in obesity. 
Aside from these exceptions, however, amenorrhea is an important 
diagnostic and prognostic factor. 

In addition there are a number of etiologic factors which, without 
appreciably impairing the function of the genital organs, i.e., without 
producing amenorrhea, nevertheless interfere with the process of con- 
ception in some imperfectly understood manner, such as the nutrition, 
mode of life, temperament, mood, hard work, worry, consanguinity, 
and indifference between husband and wife. Whether these factors 
influence the ovarian function directly or disturb some other entirely 
unknown mechanism concerned in the process of conception, is as yet 
entirely beyond our ability to determine. Every clinician of experience 
will remember cases in which, even after careful examination of the 
woman and clue consideration of all conceivable etiologic factors, the 
cause of the sterility still remains hidden and cannot be removed. 

If no cause is found in the general condition, it remains to determine 
whether any nervous disturbances are present to interfere with 
conception. 

The only process which is directly influenced by disturbances of 
the nervous apparatus is coitus, the disturbance consisting in some 
interference with the entrance of the semen into the uterus. Our 
knowledge in regard to this phase of impregnation is still 
very incomplete. It is probable that sensory irritation of 
the vulva, clitoris, and introitus sets up reflex processes in the vagina 
which manifest themselves in certain phenomena such as the discharge 
of the secretion from Bartholin's glands and contraction of the con- 
strictor cunni and levator ani muscles, presumably for the purpose of 
retaining the semen in the vagina. The general indication that the 



646 GYNECOLOGICAL DL4GNOSIS 

function of this reflex apparatus, and especially the last step in the 
process, has been normally performed, is found in the feeling of pleasure 
and terminal satisfaction; hence this is in a measure a criterion whether 
this phase in the process of impregnation is normal. Clinical- experience 
shows that conception undoubtedly occurs more frequently after coitus 
attended by great sexual excitement and a sense of complete satisfaction; 
but that, on the other hand, the sexual act may be followed by con- 
ception even in the absence of pleasure and satisfaction. Dyspareunia 
cannot, therefore, be regarded as an obstacle to conception, but it is 
a frequent complaint of sterile women and is undoubtedly in many 
instances related to sterility. The exact nature of the unfavorable 
influence in the individual case is, however, difficult to determine; 
it may be due to the following causes: 

1. Diseases of the genital organs that prevent the feeling 
of pleasure by causing pain during coitus, such as vaginism, posterior 
parametritis, perimetritis, and tubal diseases. 

2. Inadequate sensory irritation of the genitalia on 
account of excessive width of the introitus, impotence on the part of 
the man, awkwardness in performing the act, infantile genital organs. 

3. General somatic and nervous conditions that inter- 
fere with the reflex sensation of pleasure, such as general debility, cer- 
tain forms of neurasthenia and hysteria. 

4. Hysterical states that prevent sexual excitement, such as aver- 
sion for the man, contrary (perverted) sexual sensations, masturbation. 

The causes of dyspareunia sometimes coincide with those of sterility. 

The history is not altogether without importance in the diagnosis 
of the cause of sterility. In the first place the question whether the 
case is one of true sterility or habitual early abortion is determined 
by the duration of the marriage. The history may in- 
dicate whether the husband or the wife is at fault, as 
when one or the other has had children by a former marriage, or has 
had some disease such as gonorrhea which frequently causes sterility. 
It is important to determine whether the sterility is primary or second- 
ary, because the etiology is different in the two conditions. Thus, in 
cases of secondary sterility congenital causes such as anteflexion and 
stenosis may be excluded at once, and the sterility is found to be due 
usually to acquired, and in most instances inflammatory causes. Above 
all the physician should never neglect to inquire, especially in the case 
of young, inexperienced husbands, in what manner the act is performed; 
it is almost incredible how often the cause of a sterility is found in 
awkwardness or in some absolutely erroneous notion on the part of 
the husband. 



ANALYTICAL DIAGNOSIS 647 



Analytical Diagnosis of Abdominal Tumors. 

In the section devoted to special diagnosis the diagnostic features 
of every variety of abdominal tumor, so far as they can be determined 
by clinical examination, have been fully given. Nevertheless, under 
the impression that the practitioner needs some special guidance in the 
differential diagnosis of difficult cases, I shall summarize abdominal 
tumors from the standpoint of analytical diagnosis. In ordinary cases 
the diagnosis of an abdominal tumor is made about as follows. The 
physician finds a tumor in the abdomen and makes a provisional diag- 
nosis based on some prominent feature of the growth. Thus, if it is 
large and cystic, it will be taken for an ovarian tumor; if it is round and 
hard, for a myoma; if an extensive area of resistance is felt in the pelvis, 
it will be regarded as an exudate. The diagnosis is then confirmed or 
revised by seeking for further signs. But in the more difficult cases, 
in which the diagnosis is not at once suggested by some conspicuous 
sign, the physician usually vacillates between various theories and is 
very apt to dismiss the patient with a diagnosis of 'abdominal tumor.' 
For cases of this type I shall point out an analytical method by which 
a correct diagnosis can be made. Needless to say, I shall have to be 
brief and refer the reader for further studies to works on special diag- 
nosis. Nevertheless a certain amount of repetition will be unavoidable. 

Beginning with large abdominal tumors situated above the pelvic 
inlet, there are certain features of diagnostic importance which are 
determined by external examination. The most conspicuous character- 
istic of the tumor is its size, which, however, is of very little diagnostic 
value because size is not characteristic of any one kind of tumor. Never- 
theless certain genital tumors, such as encapsulated hematomata, 
exudates and tubal tumors, rarely attain such a size as to project far 
above the pelvic inlet; while, on the other hand, ovarian tumors, uterine 
myomata, in rare cases pelvic connective tissue fibromata, hydro- 
nephrosis, echinococcus cysts of the abdominal glands, and especially 
ascites, which from a diagnostic standpoint must be included among 
abdominal tumors, may attain an unusual size. 

The shape of the tumor, which is next determined, has a con- 
siderably greater diagnostic value. It is important to determine whether 
the tumor is round, or flat and diffuse; and, if the growth consists of sev- 
eral segments, whether each part is round or whether some of them merge 
with the adjoining structures without any definite boundary line. In 
a general way it may be said that all new-formations and retention- 



648 GYNECOLOGICAL DIAGNOSIS 

tumors are round or oval; this is true of ovarian tumors, rayomata, 
parovarian neoplasms, large tubal tumors, neoplasms and retention- 
cysts of the kidneys, retroperitoneal tumors, etc. An exception is 
found in malignant neoplasms which are not confined to the affected 
organ and spread into the adjoining structures. The main tumor, 
which can usually be outlined fairly well, is generally surrounded by 
numerous indistinct accessory tumors. All inflammatory tumors, 
whether peritoneal or parametrial, are characterized by flatness and a 
distinct outline. On the other hand, the shape of a hematoma may be 
quite irregular, as the blood may have forced its way between the organs 
before the occurrence of coagulation. In determining the shape of the 
tumor the surface must also be examined. Myomata of the subserous 
type have a perfectly smooth surface as if they had been turned out 
with a lathe. Some ovarian tumors also have a smooth surface ; while 
in others the surface is irregular from the presence of shallow retrac- 
tions, lobulations and prominences, especially in the case of malignant 
tumors, or on account of the papilla3 that have broken through the sur- 
face. Irregularities may also be due to adherent coils of intestines or, 
as in the case of renal tumors, to loops of intestines on the anterior 
surface of the tumor. Tortuosities usually indicate a tubal tumor. 

Next the consistency of the tumor is to be investigated, par- 
ticularly whether it is cystic or solid. Solid tumors may be hard or 
soft, and a cyst may be tense, or only partially full and flaccid. The 
consistency of a tumor is, however, the pivotal point of the differ- 
ential diagnosis in the case of the genital organs, because of the two 
different representatives — ovarian tumor and myoma — one is cystic 
and the other usually solid. It is quite difficult to make out the con- 
sistency of a tumor, and most mistakes in diagnosis are unquestionably 
due to failure to interpret this feature correctly. The abdominal 
walls form the chief obstacle, and the degree of pressure used must be 
regulated by the resistance encountered. If it can be positively deter- 
mined that the tumor is solid and that it originates in the genital organs, 
it is in a great majority of the cases a myoma. Solid ovarian tumors 
are rare, and multilocular cysts with small cavities are only hard in. 
places. In tumors of other organs a hard and solid consistency indicates 
carcinoma, while a hypertrophied liver or spleen also feels solid, but 
the consistenc)' is more elastic than hard; it is in fact a peculiar paren- 
chymatous consistency. A cystic tumor, provided ascites and a fluid 
exudate can be excluded, is most likely an ovarian cyst, more rarely 
a parovarian cyst, or a large tubal sac. Uterine tumors are rarely cystic — 
so-called cystic myomata. Among cystic tumors originating in other 
organs we have retention-tumors of the kidneys, echinococcus-cysts, 
mesenteric and retroperitoneal cysts and pancreatic cysts. 



ANALYTICAL DL-VGNOSIS 649 

The most important step in the diagnosis consists in determining 
the position of the tumor because in a large number of cases the 
tumors retain the position of the organs from which they originate. 
This is true of tumors of the liver, spleen and kidneys, except that the 
latter may be prolapsed from relaxation of their peritoneal attachments. 
The position of pancreatic cysts, omental tumors and retroperitoneal 
tumors is also characteristic. These tumors differ from genital tumors 
by the fact that the latter are situated lower down and cannot be differ- 
entiated by their position; for tumors of the uterus, as well as of the 
ovaries and parovaria, constantly tend to occupy a median position so 
long as they retain any degree of mobility. The impression which pre- 
vails among inexperienced physicians that uterine tumors must be 
situated in the median line and ovarian tumors to one side of the median 
line is erroneous; it is only when they have lost their mobility in an 
early stage of their development that a lateral situation is observed, 
as in the case of large tubal tumors. 

The mobility of a tumor may often assist in making the diag- 
nosis, as the mobility of tumors of the liver during respiration, the 
immobility of extraperitoneal tumors of the kidneys, and the immo- 
bility of tumors originating from the retroperitoneal organs in general. 
Genital tumors as a rule have a certain degree of mobility unless they 
are intraligamentary or incarcerated. Mobility in the case of genital 
tumors is of less value in the differential diagnosis than as an indication 
of the seat of the tumor. 

In many cases the above characteristics of abdominal tumor, if 
they can be accurately determined, suffice for the diagnosis. But as 
a rule the diagnosis is not absolutely positive until it has also been 
ascertained from what organ the tumor takes its origin. For our present 
purpose the main point to determine is whether the tumor originates 
in the genital organs or not. Genital tumors are characterized by the 
fact that they grow out of the true pelvis and lie upon the pelvic inlet 
or project above it, depending on their size, one segment usually remain- 
ing within the pelvis. Hence the outer contour of the tumor can be 
made out as beginning at the pelvic inlet and extending in all directions. 
On the other hand, tumors that do not originate in the genitalia can 
be distinctly delineated above the pelvic inlet, although they cannot 
be differentiated from the organ to which they belong; hence a zone 
of intestines can usually be made out by percussion and palpation between 
the lower boundary of the tumor and the pelvic inlet. While this is 
the rule, there are many exceptions. If they are very large the tumors 
may be in such intimate contact with their organs as to give the 
impression that they originate in those organs; or in exceptional cases, 
e.g., when the pelvic inlet is greatly contracted or the tumors are adherent 



650 GYNECOLOGICAL DL^GNOSIS 

to organs in the upper part of the abdomen and to the abdominal wall, 
they may be so high that their lower boundary can be plainly made out. 
Again, tumors of the hver, kidneys and spleen and large paratj^phlitic 
exudates may grow downward and disappear in the pelvis. Hence the 
origin of the tumor cannot always be determined b}^ following its out- 
lines. In these cases the mode of fixation, which may be char- 
acteristic, is of value. Genital tumors are fixed below, i.e., when the 
tumor is lifted out of the pelvic inlet with both hands a certain resist- 
ance is felt, and as soon as the tumor is released it returns to the pelvic 
inlet. Tumors originating in the liver, spleen and other organs, on the 
other hand, are fixed in a corresponding direction, and when they are 
displaced by traction they return to their original site and permit their 
connection with the organ to be palpated directly. In the case of mov- 
able kidne}^ and spleen this sign is, however, entireh^ absent, as these 
tumors are equally movable in all directions and the only indication 
of their origin is found in the fact that they can be replaced into the 
site of the corresponding kidney or spleen. The best method of differ- 
entiating between genital tumors is bimanual examination. If the 
tumor is not a genital tumor, it is possible to palpate the genitalia 
in their normal position, i.e., the uterus and both ovaries have no 
connection whatever with the tumor. LTnfortunateh* genital tumors 
cannot always be excluded in tliis way because it is not always possible 
to demonstrate both ovaries. 

After the genital nature of the tumor has been recognized in this 
wa)^ the particular organ from which the tumor takes its origin 
remains to be determined. Large tumors extending far above the pelvic 
inlet are usually derived from the uterus and ovaries. The examiner 
should always turn his attention first to the uterus. The best way of 
making sure that a large tumor is uterine is to determine its connection 
with the vaginal portion. In uniform enlargement of the uterus, as in 
pregnane)' and interstitial m5^oma, it is easy to feel the vaginal portion 
gradually broadening out and merging with the lower portion of the 
tumor; in the case of large mural tumors it is somewhat more difficult, 
as in such cases the vaginal portion merges with the peripheral portion 
of the tumor, and it may be difficult to determine whether the uterus 
is merely in contact with the tumor or forms part of it. If a peduncu- 
lated connection is felt between the tumor and the uterus, the nature 
of this connection alone must determine whether the tumor is uterine 
or not. It has often been given as a diagnostic sign that, when a uterine 
tumor is displaced by manipulation through the abdominal walls, the 
vaginal portion moves with it, and that the latter remains immovable 
when a large ovarian tumor is displaced in the same way. While this 
is true in the case of uniform enlargements of the uterus and ovarian 



ANALYTICAL DIAGNOSIS 651 

tumors with slender pedicles, the sign is a fruitful source of error in the 
case of most tumors. For, to begin with, pedunculated subserous myo- 
mata have a distinct and independent mobility of their own which 
does not at all affect the uterus; while, on the other hand, intraliga- 
mentary tumors or such as have a broad attachment to some part of 
the uterus often cannot be moved independently of the organ and 
therefore cause the vaginal portion to move with them. The merging 
of the vaginal portion with the tumor is also difficult to recognize dur- 
ing pregnancy owing to the marked softening of the lower uterine seg- 
ment, and in the presence of moderate degrees of flexion at the internal 
OS. Although the above-mentioned sign must be regarded as the most 
positive and although it can be elicited with least discomfort to the 
patient, nevertheless it has its limitations, and if it fails, resort must 
be had to sounding. A tumor is identified as a uterine tumor by finding 
the uterine cavity in its interior or along the margin. The direction 
taken by the sound as it is introduced into the tumor may suffice to 
establish this point. If not, the instrument is carefully carried as far 
as the fundus until the tip is felt in some portion of the upper or lateral 
peripher)'. Of course similar findings may be obtained if the uterus 
is partly attached to the intraligamentary tumor. Doubtful cases may 
be cleared up by measuring the cavity. In rare cases an intraligamen- 
tary tumor, not originating in the uterus, may distend the organ to such 
a degree that the cavity is appreciably increased in length; nevertheless 
elongation of the uterine cavity is one of the most reliable indications 
that the tumor is of uterine origin. Compared with these two signs, 
a third, namelj" the course of the round ligament, has but a limited 
value. If the ligaments can be plainly traced on the surface of the tumor, 
the tumor is uterine; for the round hgaments do not come in relation 
with the para-uterine tumors unless they have been displaced somewhat 
forward and upward by a broad intraligamentary development so that 
they follow an oblique course over the anterior surface of the tumor. 

If the uterine origin has been established in this manner, and the 
tumor is large and projects above the pelvic inlet, the diagnosis can only 
be myoma, pregnancy, or possibly a large sarcoma. For the differential 
diagnosis of these conditions see page 297. 

If it is certain that the tumor does not originate in the uterus, it 
must be a para-uterine tumor in the wide sense of the term. The 
only conditions which we have to consider are tumors of the ovary and 
parovarium (rarelj^ of the tubes), large extravasations of blood, occasion- 
all)' large intraperitoneal exudates, and advanced extraperitoneal preg- 
nancy. The first thing to be determined is the outline of the tumor. 
If the latter is everyw^here distinct and the tumor has a wall of its own, 
hematomata and exudates may be excluded and the tumor must be 



652 GYNECOLOGICAL DIAGNOSIS 

ovarian, parovarian or tubal. Even in the presence of complicating 
inflammatory processes in the neighborhood the wall of the tumor can 
usually be felt quite distinctly. With regard to consistency, the above- 
named tumors are usually distinctly cystic; but exudates, particularly 
of peritoneal origin, may also yield fluctuation, and occasionally a 
hematocele may remain completely cystic and simulate the consistency 
of an ovarian tumor. A distinctly outlined, cystic tumor is, judging 
by frequency, in all probability an ovarian tumor. But the dif- 
ferential diagnosis must be confirmed by demonstrating that the tumor 
is connected with the uterus by a cord or, in rare cases, by the broad 
ligament (intraligamentary tumor); for the diagnosis of parovarian 
tumors it is necessary that the ovary be felt with the pedicle on the 
same side; while tubal tumors are characterized chiefly by the thickening 
of the uterine portion of the tube and the fact that they are usually 
bilateral. If the outlines are diffuse and the growth is connected with 
neighboring structures, it suggests an inflammatory process or an 
extravasation of blood, and the further distinction between these 
two processes is made by the degree of inflammatory reaction, the 
consistency, and certain data obtained from the history (see p. 488). 

I have so far discussed only the large abdominal tumors which 
project above the pelvic inlet because these tumors, from the stand- 
point of differential diagnosis, bear a peculiar relation to tumors of the 
other abdominal organs. But the most important so-called gyneco- 
logical tumors are the small neoplasms which are contained almost 
entirely within the true pelvis. The differential diagnosis of these 
tumors is much more important to the physician because they are 
more frequent, because the differences are less marked than in the case 
of the above-mentioned large tumors, and finally because tumors of va- 
rious adjoining organs must also be taken into consideration. This group 
includes tumors of the uterus, ovaries, parovaria and tubes; hema- 
tomata and exudates of the broad ligament and of the parametrium; 
hematoceles and exudates of the peritoneal space; tumors of the bladder 
and rectum; tumors of the periosteum, of the pelvic bones and of the 
pelvic glands. The differential diagnosis of these tumors, which we group 
under the general term pelvic tumors, is exceedingly diflScult and pre- 
sents problems which even the expert speciahst is sometimes unable 
to solve. Objective examination by bilateral palpation, here as else- 
where, forms the basis for the diagnosis. We first try to ascertain from 
what organ the tumor takes its origin. If this can be determined, 
the next question in regard to the character of the tumor is much 
easier to answer. 

The examination is begun by looking for the uterus, partly in order 
to determine whether the organ itself is the seat of the tumor, and 



ANALYTICAL DL^GNOSIS 653 

partly, in case it is not, to obtain an important landmark by which to 
locate the tumor; for its position with reference to the uterus, whether 
it is ante-uterine, retro-uterine or para-uterine, or, in the case of several 
tumors, whether they are all on the same side of the uterus or bilateral — 
all these are important diagnostic points. The vaginal portion should 
be traced up into the tumor until the uterus is discovered. If the 
enlargement is uniform, as in the case of interstitial myomata, the organ 
may be found at once; not so, however, when the enlargement is irregu- 
lar, because in that case the vaginal portion is joined to some portion 
of the periphery of the tumor and it is difficult to decide whether the 
tumor originates in the uterus or is merely para-uterine. This point 
must be decided by the width and character of the connection. When 
a tumor is merely in apposition with the uterus, a furrow can usually 
be recognized running the entire width of the connection between the 
tumor and uterus; while uterine tumors have a large or small pedicle 
growing directly out of the uterine substance. Doubtful cases must be 
cleared up with the sound, which almost always shows the cavity 
enlarged in uterine tumors. The adnexa and round ligaments cannot 
usually be palpated with any degree of certainty. If the uterus cannot 
be recognized by following the vaginal portion; if the organ is sur- 
rounded by several tumors of similar shape, such as subserous myomata; 
or if the contour of the organ is completely obscured by surrounding 
tumors of the adnexa, it may sometimes be identified by its consistency, 
which is softer than that of the surrounding tissue in the case of 
myomata, and harder than soft and cystic adnexal tumors. Sometimes 
the uterus may be discovered by palpating the entire periphery of the 
tumor with a succession of short taps and noting at what point the 
movement is transmitted best to the vaginal portion. In all doubtful 
cases the sound should be employed, unless the tumors forbid its use — ■ 
tubal tumors, exudates, hematocele, intra-uterine and extra-uterine 
pregnancy. The direction of the sound shows where the body of the 
uterus is to be found, or it may be located by palpating the head of the 
sound through the abdomen with the external hand. 

After it has been ascertained that the tumor belongs to the uterus 
alone, we must decide whether it represents a uniform enlargement of the 
uterus or is connected with it by a pedicle. Tumors of the latter class 
are always found to be either subserous myomata or sarcomata. If the 
tumor represents a uniform enlargement of the uterus, its consistency 
is compared with the normal consistency of the organ. Enlargements 
that are softer than the normal uterus indicate pregnancy, abortion 
or puerperal softening; while increased hardness points to chronic 
metritis, myoma or carcinoma. For the further differentiation of these 
conditions see p. 280. 



654 GYNECOLOGICAL DIAGNOSIS 

If the tumor does not originate in the uterus, the diag- 
nosis must be based on certain inherent qualities of the growth itself. 
If it is CA'stic, as determined by the presence of fluctuation, it is either 
an ovarian tumor, a tubal retention-cyst — especially hydrosalpinx — 
a parovarian tumor, or a recent pelvic exudate or hematocele. Those 
tumors may occupy any position around the uterus, but they have 
certain seats of predilection which ma}' also be utilized in (he 
differential diagnosis. Exudates and hematomata are most apt to 
collect in Douglas' space, while small tubal and ovarian tumors usually 
remain near the mother organ; but since adnexal tumors may also 
occupy Douglas' space, the difference between fluid hematoceles and 
exudates on the one hand and ovarian tumors on the other, whicli are 
detailed on p. 477, must also be taken into consid(>ration. A laterally 
situated cystic tumor probably originates in the tube and ovary, as a 
peritoneal, distinctly cystic tumor rarely occui)ies a lateral position. 
The differences between tubal antl ovarian tumors have been discussed 
on p. 462. Solid tumors represent a much larger contingent, espe- 
cially if we include small ovarian cysts and particularly the thick-walled 
dermoid growths, which are frequently mistaken for solid tumors. 
If the growth is solid, recent peritoneal exudates and hematocele are 
at once excluded, although a coagulatetl hematocele and an exudate 
during the stage of absorption may feel not only solid but often 
distinctly hard. 

After it has been found that the consistency is hard, the shape 
of the tumor is investigated in the hope of finding out what organ is 
diseased. If the outline is practically round or oval, the tumor probably 
originates in the ovary or tube; if the mass is flat it probably represents 
a portion of a tumor situated in the pelvic connective tissue. But there 
are many exceptions. Tubal tumors, especially pyosalpinx, may be 
associated with parametrial exudates and in that case exhibit qualities 
belonging to both tumors; or malignant ovarian tumors may, by infect- 
ing the pelvic connective tissue through the pedicle, produce extensive, 
flat, hard masses. On the other hand, a parametritic exudate may be 
round at the points where it is surrounded by peritoneum. The best 
way to guard against an error of this kind is to examine the entire 
outline of the tumor. If we decide that the tumor is in the pelvic con- 
nective tissue, it must be an exudate; for a carcinomatous growth, 
which yields similar palpatory findings, presupposes a primary focus. 
For further diflerential signs, especially in cases of recurrence, see p. 
49L If the parametrium is excluded, on the other hand, the distinction 
between tubal and ovarian tumors must be made by the signs given on 
p. 462. Solid ovarian tumors may be further subdivided into neoplasms 
(fibroma, fibrosarcoma, sarcoma, carcinoma) and oophoritis; while 



ANALYTICAL DIAGNOSIS 655 

hard tubal tumors may represent pyosalpinx, tubal moles following 
pregnancy, or neoplasms. For the differences see p. 463. 

The diagnosis of intraligamentary tumors calls for separate dis- 
cussion because certain characteristic properties of the tumors are 
obscured by the covering of connective tissue and peritoneum. The 
connection between the tumor and the uterus is less distinct; the shell 
of infiltrated connective tissue veils the contour and consistency of the 
tumor itself; tubal tumors are prevented from developing their char- 
acteristic shape; in short, the diagnosis of these tumors is very much 
more difficult. After the diagnosis of intraligamentary tumor has been 
positively made (see p. 322) and the uterine origin has been positively 
excluded, we must find out first whether the tumor is cystic or solid. 
If the walls are thick, forcible pressure must be employed for this pur- 
pose, and if this fails, the consistency must be tested through the rectum, 
which is often in contact with that portion of the tumor which is not 
intraligamentary. A cystic consistency indicates a parovarian, 
ovarian or tubal tumor (especially hydrosalpinx), or a fluid hema- 
toma; the differences between these conditions are often exceedingly 
obscure. The diagnosis is even more difficult if the tumor is solid 
or if fluctuation cannot be positively demonstrated. The further dif- 
ferentiation of solid tumors is carried out in approximately the same 
manner as in the case of extraligamentary tumors, except that it is 
more difficult to recognize the various characteristics of the tumors. 
In the case of intraligamentary ovarian tumors the diagnosis 
is difficult because they are usually small papillary growths with distinct 
fluctuation and, if they are carcinomatous, infect the neighborhood 
so that their outlines become quite diffuse. Tubal tumors, espe- 
cially pus-tubes, are usually surrounded by a thick shell of infiltrated 
tissue and fluctuation is difficult to detect. For the same reason the 
shape is indistinct, and even in hydrosalpinx covered merely with peri- 
toneum it is difficult to recognize the characteristic convolutions, and 
the tubal origin is revealed only by the infiltrated uterine extremity. 
An intraligamentary exudate may closely resemble a myoma because 
it is smooth above and broadly attached to the uterus, especially if it 
does not extend into the deeper portions of the parametrium. Intra- 
ligamentary hematoma soon becomes hard and round and on 
palpation presents altogether diff'erent signs from those obtained with 
intraperitoneal extravasations of blood. The diff'crential diagnosis of 
these conditions is very difficult and we are compelled to resort to the 
history antl to observation of the patient more frequently than in the 
case of other tumors. 

In the case of the true pelvis it is by no means so important to 
decide whether we are dealing with tumors of the genitalia or with 



656 GYNECOLOGICAL DIAGNOSIS 

tumors of neighboring organs, as in the case of the large tumors 
previously described, because, owing to the hmited space within the 
true pelvis, they soon come into such intimate relation with the genital 
organs that the diagnostic signs given in connection with the larger 
tumors are of no value. Nevertheless these tumors are, if possible, 
to be differentiated from the genitalia themselves, and it should at least 
be determined whether uterus and ovaries are normal. In this way it 
is possible to distinguish tumors of the periosteum., the pelvic bones, 
the pelvic glands, paratyphlitic exudates, and usually also tumors of 
the bladder and rectum from genital tumors. But if the pelvic con- 
nective tissue is included among the genital organs, as it must be for 
gynecologic purposes, certain difficulties arise; for there are certain 
forms of parametritic exudates which during the stage of absorption 
separate from the uterus and spread out along the pelvic bones in such 
a manner as to simulate bony tumors. The same thing occurs when 
these parts of the pelvis become the seat of carcinomatous neoplasms 
and recurrences. Owing to the intimate connection of these tumors 
with the genitalia it is often very difficult to make sure that the tumor 
does not originate in the sexual organs. I have experienced this diffi- 
culty several times in cases of rectal carcinoma which had involved 
the paraproctitic tissue as far as the uterus and simulated an exudate 
at this point, until the case was cleared up by a rectal examination. 
I shall not carry this analytical discussion of the diagnosis of pelvic 
tumors any farther and refer the reader to the part devoted to special 
diagnosis for a study of the diagnostic signs of the individual tumors. 
It is merely my intention to indicate the manner in which the general 
practitioner arrives at a correct diagnosis by combined examination. 
To what extent the symptomatology, the history, and observation of 
the patient may assist in making the diagnosis has also been explained 
in the part devoted to special diagnosis. 



GENERAL INDEX 



Abdomen, auscultation of, 3 

preparation of, 10 
Abdominal tumors, differential diagnosis of, 9 

walls, resistance of, 13 
Abortion, adherent placenta in, 140 
cause of, diagnosis, 143 
complete, 141 
diagnosis, 136 

based on the fetal parts, 137 

on obstetrical changes, 137 
hemorrhage, 136, 142 
labor pains, 136, 142 
dilatation of the cervix, 137, 140 
early, differential diagnosis, 164 
inevitable, 142 
palpatory findings in, 137 
putrid, 143 

stages of, beginning abortion with intact 
ovxun, 138 
complete abortion, 138 
diagnosis of, 138, 140 
incomplete abortion (retention of 

fetal parts), 138 
threatened abortion, 138, 139 
symptoms, diagnosis from, 136 
threatened, 142 
tubal, 147 

hemorrhages into the tube, 147 
Adenocarcinoma, 399, 400, 414 

fenestratum, 414 
Adenoma, 538 
benign, 538 
everting, 418, 419 

maUgnant, 541 
inverting, 418, 419 
malignant, 540 
malignant, 200, 393, 398, 399, 400, 414, 
540 
of vaginal portion, 403, 404 
Adenomyoma, 292, 442 

malignant, 445 
Adhesion-cysts. 476 
Adhesions, parametritic, 453 
perimetritic, 453 
peritonitic, 479 
Amenorrhea, 546, 616 
causes of, 615-620 
^42 



Amenorrhea, limitations of, 615 

ovarian, 617 

uterine, 616 
Anesthetics, 15 

Anteflexion, in dysmenorrhea, 237, 626 
Anus, 76, 546 
Appendicitis, 464 

differential diagnosis from tubal preg- 
nancy, 166 
Arteries, internal spermatic, 96 

ovarian, 96 

palpation of, 98 

spermatic, 97 

uterine, 97 

vaginal, 97 
Ascher, 633 
Ascites, differential diagnosis, 133, 307, 313 

ovarian, differential diagnosis, 316 
Atrophia senilis praecox, 116 
Azoospermia, 633 

Bacterial diagnosis, gonorrhea, 64 

pyogenic micro-organisms, 67 
tuberculosis, 65 
Bacteriologic diagnosis, 64 

examination, 43 
Bartholinitis, gonorrheal, 384 
Bartholin's glands, 77 

carcinoma of, 384, 438 
cysts of, 384 

in gonorrhea, 524 
gonorrheal suppuration of, 524 
histology, 101, 102 
tumors of, 383, 384 
Bivalve speculmn, 25 
Bladder, 91 

calculi in, 571 

catarrh of (see also Cystitis), 56 
continence of, 557 
contraction of, 570 
diseases of, 563-572 

displacement of, in retroversioflexion, 245 
distention of, differential diagnosis, 309 
foreign bodies in, 56, 571, 585 
palpation of, 92 
papillary fibromata, 210 
tumors of (see also under Tumors), 56, 571 

657 



658 



GENERAL INDEX 



Blood mole, 177 

Breasts, changes during pregnancy, 130 

Broad ligaments, 84, 87 

hematoma of the, 151 
Bumm, 203 

Calculi, urethral, 563 

vesical, 571, 583, 584 
cystoscopy, 584 
radiography, 584 
Cancer, see Carcinoma. 
Cancroid, histblogy of, 401 

of the uterine mucosa, 414 
Carcinoma adenoides, 399, 414 
alveolare, 396, 410 
architecture of, 390, 393 
cervical, diagnosis, 355 

differential diagnosis, 357 
complicating myoma, 288 
definition, 389 
differential diagnosis of, 431 
glandulare, 399, 410 
fenestratimi, 398 
papillare alveolare, 398 
horny, 414 

infiltrating, differential diagnosis, 351 
periurethral, 562 

polypoid, differential diagnosis, 349 
primary ovarian, 331 
syncytiale, 421 
urethral, 562 

uterine body, diagnosis, 357 
classification, 337 
extension of, 359-365 
metastasis, 366 
recurrence, 367 
glandular, 369 
local, 367 
metastatic, 369 
vaginal, diagnosis and differential diag- 
nosis, 378 
vesical, 581, 582 
worm-eaten, 411, 421 
Carcinomatous infiltrations, differential diag- 
nosis, 490 
plugs, 101 
Carcinosarcoma, 433 
Cardinal ligament, 91 
Caruncle, 562 

Carunculse myrtiformes, 78 
Casper, 54, 55, 590, 591 

and Stockel, 58 
Casper's endoscope, 559 

ureteral cystoscope, 57 
Catamenia, see Menstruation. 



Catarrh, cervical, 513, 640 

acute, in gonorrhea, 524 
chronic, 357 
definition, 513 
diagnosis, 513 
differential diagnosis, 516 
physical signs, 514 
secretion in, 515, 516 
chronic cervical, 357 
gonorrheal, 461 
uterine, classification, 501 
definition, 501 
diagnosis, 501 

of extension, 521 
vaginal, 638 
Catheterization of the ureters, 56, 57 
indications, 58 
technic, 58 
Catheters, 590, 591 
Cavernous tissue, 121 
Cavum corporis uteri, see Uterine cavity. 

prseperitoneale Retzii, 91 
Cervical canal, liistology, 107 
glands, 109, 110 
goblet-cells. 111 
Cervicitis, periglandular, 542 
Cervix, 80 

adenoma, malignant, 410, 411 
blood-vessels, 97 
carcinoma of, 337, 340 
histology of, 409 
infiltrating, 341 
carcinomatous ulcer, 341 
elongation of, 640 
hemorrhage from, 609 
histology, 106, 108, 120 
mucous polyps, 350, 445 

differential diagnosis, 350 
polypoid proliferations in, 429 

sarcomata of, 372 
racemose sarcoma of, 372 
sarcoma, 370 
stenosis of, 31, 639 
tumors of, 640 
Cessation of menstruation, as a sign of preg 

nancy, 130, 131 
Chancroids, differential diagnosis, 354 
Chloroform, 15 
Chondroma, 436 
Chondrosarcoma. 436 
Chorionepithelioma, 425 
benign, 184, 423 
in the male, 422 
malignant, 421 
malignum, 184, 187 



GENERAL INDEX 



659 



Chorionic epitheliiun, 1S4 

vim, 17S 
Chromo-cystoscopy, 55 
Climacteric, histologic changes in, 118, llo 

IIG, 120 
Clitoris, 76, 77, 546 

liistology, 102 
Cloaca, 546 
Colic, renal, 590 
Colpitis, 501, 517 
definition, 517 
diagnosis, 517 
differential diagnosis, 519 
diphtheritic, 51S 
emphysematosa, 51S 
gonorrheal, 524 
granularis, 517 
maculosa, in gonorrhea, 524 
secretion in, 518 
Colpos unilateralis, 554 
Cohmmse rugarimi, 78, 79 
Conception, mechanism of, 634-636 
Condylomata acmninata, 3S3, 562 
differential diagnosis, 351 
in colpitis, 518 
in gonorrhea, 524 
elephantiasis vulvae, 383 
Congenital erosion, 108 
Craurosis \'ulviE, 520 
Curettage, exploratory, 39 
Curve of Carus, 79, SO 
Cystadenoma pseudomucinosum, 329 
serosum, 330 
imiloeular, 312 
Cystitis, 566 
acute, 570 
ascending, 586 
catheter, 589 
chronic, 570 

cystoscopic picture, 568, 569 
gonorrheal, 570 
tuberculous, 570 
urinary findings, 567 
Cystocele, 221, 231 

cystoscopy, 232 
Cystoma glandulare proliferans, 330 

serosum simplex, simple serous cysts, 329 
Cystoscope, 92, 93 

Casper's ureteral, 57 
Kelly's, 59 
Nitze's, 53 
Nitze and Casper, 58 
sterilization of, 54 
Cystoscopic findings, 92, 93 
Cystoscopy, 52 



Cystoscopj'', contraindication, 54 
in diagnosis of fistulte, 575 
in examination for foreign bodies, 586 

for stone, 584 
indications, 56 
Kelly method of, 59 

postures of patient, 59 
renal tumors, 595, 596 
technic, 54, 55, 60-64 
trnnors of the bladder, 581 
ureteritis, 586 
Cysts, corpus luteum, 329 
dermoid, 331, 332 
follicular, 329 
inflammatory, 329 
multilocular ovarian, 312 
myxoid ovarian, differential diagnosis, 315 
ovarian, dift'erential chagnosis, 312-321 

exploratory puncture, 317 
pancreatic, differential diagnosis, 318 
proliferating glandular, 329 

papillary, 330 
simple serous, 329 
tubo-ovarian, 329 

Decidua, 178, 188 

basilaris, 177, 184, 199, 200, 202 
capsularis, 200 
cirrhotic, 199 
graviditatis, 205 
menstruaUs, 207 
polyposa, 198 
reflexa, 177 
serotina, 202 
tuberosa, 198 

vera, 189, 190, 191, 193, 194, 195, 199 
Degeneratio hydatidosa circumscripta, 187 
Diagnosis, analytical, 602 
bacteriologic, 64 
general, 1 
gonorrhea, 64 
gynecologic, 1 
microscopic, 38 
special, 76 
tuberculosis, 65 
cultures, 66 
inoculation, 66 
Dilatation of cervix in abortion, 137, 140 

of external os, 34 
Dilators, 35 

Goodell-Elhnger, 41 
hard-rubber, 35 
Hegar's, 20 
laminaria tents, 35 
Schroder and Landau's, 35 



660 



GENERAL INDEX 



Disinfection of the hand, 11 

Displacements of the uterus, 211 

Douglas' space, 83 

Ducts of Gartner, 54.5 

Diihrssen, 121 

Dutzmann, 468 

Dysmenorrhea, anteflexion in, 626 

causes of, 621-630 

classification, 623 

definition, 621 

endometritic, 628 

mechanical, 626 

membranous, 196, 197, 512 
differential diagnosis, 198 

nasal, 629 

nervous, 629 

ovarian, 623 

tubal, 624 

uterine, 624 
Dyspareimia, 645 
Dystopia of the kidneys, 600 
Dysuria, 563, 564 

causes of, 571 

Ebermann, 563 

Echinococcus cysts, differential diagnosis, 

sacs, differential diagnosis, 309 
Ectodermal layer, 181, 184, 185, 188 

(layer of Langhans), 182 
Ectropion, 110, 514, 515 

differential diagnosis, 516 
Endometritis, 501, 542 

acute septic (non-puerperal), 510 
atrophicans, histology, 535 
catarrhal, 510 
cause of sterility, 642 
cervical, 501 

histology, 542 
cervicalis papillaris, 543 
corporeal, 501 

diagnosis, microscopic, 526 
histology, 542 
deciduacellaris, 539 
decidual, 198, 512 
diagnosis, 502 

microscopic, 509, 526 
differential diagnosis, 509 
dysmenorrheic, 512 
exfoliating, 512 
exfoliative, 209 
fundi, 628 
fungous, 511 

histology, 535, 537 
glandular, 196, 538 
decidual, 199 



320 



Endometritis, glandular, histology, 529 
interstitial, histology, 528 
glandularis ectatica cystica interstitialis 
chronica, 534 
papillaris, 540 
profunda, histology, 531 

interstitialis superficialis, 533, 538 
gonorrheal, 511 
hemorrhage in, 503 
interglandularis, 526 
interstitial, 198, 199 

histology, 526 
interstitialis deciduacellularis, histology, 
529 
exudativa glandularis hemorrhagica, 

207 
glandularis exudativa, 533 
histology, 533 
leucorrhea in, 503 
membranous, 117 
objective signs in, 507, 508 
pain, intermediate, 506 

uterine, 505, 506 
periglandular interstitial, 434 
souncUng in, 507 
suppurative, in gonorrhea, 524 
symptoms, 502 

premenstrual, 506, 507 
tuberculous, 511 
Endometrium, hyperesthesia of, 629 
sclerosis of, 116 
senile atrophic, 116 
Endosalpingitis, 501 
Endoscopes, Casper's, 559 
Endoscopy, 559, 563 
Endothelioma, 434, 435 
glandular, 436 
ovarian, 333 
verum, 394 
Epidermidalization, 105, 110, 406, 407, 543 
Epithelial hematomata of Gebhard, 116 
hoods, 181, 182, 183 
processes, 182, 183 

(villous plugs), 182 
Epoophoron, 85, 545 
Erosion, 352, 402, 514 

-carcinoma, histology of, 401 
cervical, 544 
congenital, 108 

histology of, 408 
differential diagnosis, 352, 516 
follicular, 402, 514 
healing of, 407 
papillary, 352, 402, 514 
simple, 402, 514 



GENERAL INDEX 



661 



Ether, 15 
Ethyl chlorid, 15 
Examination, bacterial, 43 
bed, 5 
bladder, 20 
combined, 4, 7 

recto-vaginal, 19 
cystoscope, 20 
external, 1 

Freund (Trendelenburg) position, 9 
general (chloroform) anesthesia, 14 
gynecological, 1 
internal, 3, 12, 13 
position of hands in combined, 17 

of patient, 4 
Profanter's method of, 10 
rectal, 18 
rubber glove, 12 
standing posture, 10 
technic of combined, 15 
Examining-chair, 6, 7, 16 
-couch, 5, 6 
-table, 5 
Excision, exploratory, 41 
Exploratory curettage, 39 

contraindications, 41 
indications, 41 
technic, 40 
excision. 41 

indications, 42 
technic, 42 
External os, 80 

dilatation of, 34 
stenosis of, 638 
Extra-uterine pregnancy, see Pregnancy, 

extra-uterine. 
Exudate, intraligamentary, 655 

parametritic, see Parametritic exudate, 
absorption in, 493 

diagnosis of certain special condi- 
tions, 493 
leucocytosis in, 494 
prognosis, 493 
rupture of, 495 
suppuration of, 494 
paratyphlitic, differential diagnosis, 490 
perimetritic, differential dJagnosis, 491 
peritoneal, differential diagnosis, 307 
perityphlitic, differential diagnosis, 490 

Fallopian tube, 84, 90 

closure as a cause of sterility, 642 
during menstruation, 123 
histology, 123 
neoplasms of, 469 



Fallopian tube, palpation of, 90 
papillomata, 469 
pregnancy, 123 
retroversioflexion, 245 
Female genital organs, blood-vessels, 96 

normal palpatory findings, 76 
topographic anatomy, 76 
Ferguson's speculum, 25 
Fetal heart sounds, 129 

movements, 129 

parts, palpation of, 130 
Fibrin-membranes, 205 
Fibromata, ovarian, 333 

urethral, 563 
Fibrosarcoma, ovarian, 333 
Fimbria ovarica, 90 
Fistula, ureteral, 574 

cystoscopy in, 576 

uretero-uterine, 575 

urethro-vaginal, 574 

urogenital, 572-576 
cystoscopy in, 575 

vesical, 574 

vesico-uterine, 574 

vesico-vaginal, 574 
Fixation, diagnosis, 251, 254 

indirect, 255 

intraperitoneal or perimetritic, 254 

parametritic, 254 
Fliess, 629 
Fluor albus, 104 
Folds of Douglas, 85 
Foreign bodies, in bladder, 571, 585 

in urethra, 563 
Fossa navicularis, 77 
Franz, 478 
Frenulum, 76, 77 
Fundus uteri, 80 
Fiirbringer, 633 
Furst, 546 

Gartner's canal, 103 

duct, 105, 122 
Gebhard, 195, 197, 207 

epithelial hematomata of, 116 
Gebhard-Opitz glands of pregnancy, 400 
Genital eminence, 546 

folds, 546 
Genitaha, external, development, 546 

internal, classification, 546 
development, 545 
malformations, 545-556 
Germinal glands, 545 
Glands, Barthohn's, 77, 101, 102 

cervical, 109, 110 



662 



GENERAL INDEX 



Glands, germinal, 545 

hypogastric, 96 

iliac, 96 

inguinal, 96 

lumbar, 96 

Montgomery's, 130 

Opitz-Gebhard, see under Opitz-Gebhard. 

pelvic, 96 

pregnancy, see Opitz-Gebhard glands. 

sacral, 96 

sebaceous, 98 

Skene's, 103 

sweat, 99 

uterine. 111, 113, 114 

vaginal, 104 

V. Preuschen's, 105 
Glandular endometritis, 538 
Goblet-cells, cervical. 111 
Gonococci, 65 
Gonorrhea, cysts of Bartholin 's glands in, 524 

diagnosis of, 64, 522 
bacterioscopic, 524 
clinical, 523 

positive signs, 523 

probable signs, 524 

recent purulent urethritis in, 523 

uncertain signs, 524 

ureter, 587 

urethritis in, 524 
Goodell-EUinger dilator, 41 
Graafian follicle, 622 
Gravid uterus, retroflexion of, 479 
Ground-glass specula, 21 

speculum of Carl Mayer, 21 
Gynecologic diagnosis, anamnesis, 70 

methods of and general discussion, 

68-75 
observation of the patient, 74 
symptoms, 71 
technic of history-making, 72 

Hegar's dilators, 20 

sign in abortion, 138 

signs of pregnancy, 128, 129 
Hematocele, peritubal, 150, 151 

retro-uterine, 14S, 149, 478 

differential diagnosis, 167.. 304 
Hematocolpos, 547 

histology, 105 
Hematoma of the broad ligament, 151 

differential diagnosis, 488 

intraligamentary, 655 

ovarii, 623 
Hematometra, differential diagnosis from 
pregnancy, 132 



Hematometra unilateralis, 554 
Hematosalpinx, 457, 458, 467 
Hematuria, 56, 563 
Hemorrhage, abortion, 136, 137, 142 

absence of abnormal physical signs, 611 

appearance of the blood, 613 

causes of, 604 

climacteric, 612 

internal diseases, 613 

menopause, 606 

ovarian, 610 

pelvic peritonitis, 611 

secondary uterine, 610 

source of, 607-615 

uterine, 609 

diagnosis of, 33 

tubal, 610 

vagina, 607 

vulva, 607 ■ 
Hermaphroditism, 636 
Hidroadenoma subcutaneum, 437 
Hidroadenomata, 438 
Ilinterdamm, 76 

Histology of female genital organs, 98-123 
Hofmeier, 203 
Hunner, 59, 63 

Hydatid mole, 184, 186, 187, 188 
Hydrometra vmilateralis, 554 
Hydronephrosis, 592 
Hydrorrhea uteri gravidi, 513 
Hydrosalpinx, 454, 455, 456, 458, 462, 467, 476 

flaccid, 477 

gonorrhea, 524 
Hypogastric glands, 96 
Hymen, 76, 77, 546 

atresia of, 636 

histology, 102 

Icing-carcinoma, 396, 410, 113 
Iliac glands, 96 
Impotentia coeundi, 546 
Incontinence, causes of, 572, 576 

definition, 572 

diagnosis, 572 

retention, 578 
Inflammations, parametritic, 460, 461 

perimetritic, 460 
Infundibulopelvic ligament, 85 
Inguinal glands, 96 
Inspection, 2 

of the abdomen, 2 
Internal os, 81, 84 
Interstitial gestation, 173 
Intra-uterine tumors, palpation of, 29 
Introitus, bluish discoloration, 125 



GENERAL INDEX 



663 



Introicus, changes during pregnancy, 125 
Ischuria, 563 

causes of, 577-580 

definition, 577 

functional, 573 

mechanical, 578 

paradoxical, 578 

Kaltenbach, 604 

Kehrer, 633 

Kelly method of cystoscopy, 59 

postures of patient, 59 

and Noble, 59 

speculum, 59 
Kelly's cystoscope, 59 
Kidneys, diseases of, 5S9 

dystopia of, 600 

movable, diagnosis, 597 

differential diagnosis, 598-600 
Knee-chest position, 10, 59, 61 

-elbow position, 59 
Knorr, 53, 633 
Kossman, 421 
Kiistner, 253 

Labia majora, 76 

histology, 98 
minora, 76, 77, 546 
histology, 102 
Labor pains, abortion, 136, 142 

decidual endometritis, 513 
Laminaria tents, 35 

contraindications to use of, 38 
disinfection of, 36 
Langhans' cellular layer, 181, 183, 185, 422 
Lanugo hair, 99 
Leucorrhea, 104 
Lier, 633 

Ligaments, broad, 84, 91 
cardinal, 91 
infundibulopelvic, 85 
ovarian, 88 
round, 85, 87 
sacro-uterine, 85, 87 
Living fetus, diagnosis of, 157 
Lower uterine segment, 120 

obliteration in pregnancy, 129 
softening of, 128 
Lumbar glands, 96 
Lupus vulvae, 386 
Luschka, 85 
Lutein-cells, 186 
Luys, 591 

Lymphadenoma malignum, 436 
Lymphocarcinoma, 421 
Lymphosarcoma, 433 



Marchand, 421 

Mayer, ground-glass speculum of, 21 

Membranes, decidual, 209 

dysmenorrheic, 205, 207, 208 
fibrin, 205 
organized, 206 
sarcoma, metastases, 371 
mucous, 370 
mural, 371 
unorganized, 206 
Menge, 465 

Menopause, see Climacteric. 
Menorrhagia, 605 
Menstruation, 116, 117 
new-born infants, 117 
normal, 622 
pregnancy, 131 
Mesovarium, 88 
Metaplasia, 398, 414 
Meteorism, in differential diagnosis, 133 
Metritis, chronic, differential diagnosis from 
pregnancy, 132 
colli, 351, 514, 515 
Metrorrhagia, 605 

Meyer, R., 103, 121, 122, 195, 202, 423 
Microscopic diagnosis, 38 

examination of fluids, 42 
limitations of, 52 
purposes of, 50 
sources of error, 50 
of tissue, 42 

embedding in celloidin, 45 
embedding in parafE^n, 46 
frozen sections, 45 
staining, 47, 48 
technic, 43-52 
Missed abortion, 134 
Mole, blood, 177 

hydatid, 186, 187, 188, 202, 203 
hydatidiform, 428 
tubal, diagnosis of, 159 
Molluscura, 444 
Mons ureteris, 63 

veneris, 76 
Montgomery's glands, changes during preg- 
nancy, 130 
Mucosa corporis uteri, 111 
Mucous polyps, 439 
Muller's duct, 545, 546, 551 
Muscle rhomboids, 120 
Myoma, 439, 440 

benign metamorphosis, 442 
calcification in, 443 
capsule-formation in, 119 
cause of sterility, 641 



664 



GENERAL INDEX 



Myoma, cervical, 261 

differential diagnosis, 351 

interstitial, 261, 266 

submucous, 262 

subserous, 261 
complications, diagnosis of, 283 

urinary, 286 
consistency, 262 
cystoscojDy, 287 
degenerations of, 288 

sarcomatous, 443 
diagnosis of, 265 
differential diagnosis, 277, 301 
from pregnancy, 133 
interstitial, 357 

differential diagnosis, 278 

total necrosis of, 201 
intraligamentary, diagnosis, 270 
mobility, 264 

palpation of the adnexa, 271 
palpatory properties, 262 
pendulans, 440 
pregnancy, 202 

sarcomatous degeneration in, 443 
shape, 262 
softening of, 291 
sounding in, 274 
submucous, diagnosis, 267 

differential diagnosis, 280 
subperitoneal, diagnosis, 271 
subserous, diagnosis, 269 

differential diagnosis, 277, 321, 486 
topography, 258 
tvidsting of the pedicle, 286 
uterine, 258, 441 

interstitial, 259 
intraligamentary, 258 

intraparietal, 259 

submucous, 260 

subperitoneal, 259 

subserous, 258, 260 
Myosarcoma, 439 

Nagel, 546 

Necrospermia, 633 

Neumann, 188, 606 

Neurosis, vesical, 572 

New-born infants, menstruation of, 117 

Nitabuch, 200 

Nitze, 55 

and Casper cystoscopes, 58 
Nitze 's cystoscope, 53 
Nitrous oxid, 15 

Oberlander, 633 



Obesity, differential diagnosis, 133 
Oidium albicans, 43, 210 
Oligospermia, 633 
Olshausen, 191 
Oophoritis, acute, 333 

cause of sterility, 643 

chronic, 334 

differential diagnosis, 301 
Opitz-Gebhard glands of pregnancy, 189, 190, 

191, 197, 198, 199, 427, 428, 431 
Ovarian gestation, 173 

ligament, 88 

tumors, 293 

cause of sterility, 643 
differential diagnosis, 133, 596 
Ovaries, 84, 87, 88, 545 

atrophy, as a cause of sterility, 643 

hernia of, 550 

hypoplasia, as a cause of sterility, 643 

palpation of, 88 

retroversioflexion, 245 

suspensory ligament of, 88 
Ovula Nabotlii, 395, 402, 403, 407, 446, 514, 

543 
Ovum-space, 200 

Pampiniform plexus, 98 

Pankow, 468 

Palpation, of the abdomen, 2 

adnexa, 12 

bimanual, 4, 10 
Papilloma, superficial, 331 

vesical, 447, 581 
Paracolpium, 91 
Paracystitis, 480 
Paracystium, 91 
Parametritic exudate, 480, 481, 482 

differential diagnosis, 486-492 
Parametritis, 480 

atrophicans, 499 

cause of sterility, 644 

double posterior, 499 

gonorrheal, 497 

liistory of, 486 

posterior, 498 

retrahens, 498 

diagnosis, 498 
differential diagnosis, 500 

septic, non-puerperal, 497 
puerperal, 497 
Parametrium, 90 
Paraproctitis, 480 
Paraproctium, 91 
Paroophoron, 85 
Parovarium, 545 



GENERAL INDEX 



6G.5 



Parovarian cyst, 463 

differential diagnosis, 312 
ducts, 123 
Pehic axis. 79, 80 
exudate, 475 
gland-s, 96 

palpation, 96 
peritonitis, 470, 473 

cause of sterility, 644 
exudate, 475 
recent, 474 
Pelvis, bony parts, 95 

lymphatics and h-mph-glands, 96 
muscles, 96 
Percussion of the abdomen, 3 

trimanual. 8, 9 
Perimetritis, 470 
Perineum, 546 
Perioophoritis, 470 

cause of steriUty, 643 
gonorrhea. 524 
Perisalpingitis, 470 

in gonorrhea, 524 
PeritheUoma, ovarian. 333 
Peritoneum, line of firm attachment to uterus, 
120, 121, 122 
line of loose attachment to uterus, 121, 
122 
Peritonitis, carcinomatous, 473 
diffuse, 470 
general, 470 
gonorrheal, 473 
infectious, 471 
non-infectious, 471 
pehdc, 473 
septic, 471 
tuberculous, 472 
Perityphlitis, 464 
Peters, Hubert, 201 
Pfannenstiel; 330 
Polyps, cervical, histology- of, 430 
fibrous, 444 

differential diagnosis, 281 
follicular. 543 
mucous, 440, 444, 514, 515, 562, 563 

differential diagnosis, 281 
myomatoiis, 440 
pedunculated, 440 
placental, 439 
urethral, 446 
vascular, 562 
Polj-pus fibromuscularis glandularis, 441 

mueosus corporis interstitialis (glandu- 
laris), 444 
muscularis, 441 



Position, dorso-coccygeal, 4 
knee-chest, 10, 59, 61 
knee-elbow, 59 
Sims', 10 
Trendelenburg, 10 
Posterior vaginal enterocele, 222 
Potentia coeundi et generandi, 633 
Pregnancy, abdominal, 143 

ces-sation of menstruation in, 130, 131 
dead fetus, arrest in the grow'th of the 
uterus, 135 
diagnosis of, 134 
Hegar's sign in, 129 
hemorrhage, 136, 137 
symptoms, 136 
differential diagnosis, 131-133 

from chronic metritis, 132 
from ovarian cysts, 326 
from ovarian timiors, 309 
disturbances of, diagnosis, 131 
extra-uterine, classification, 143 
definition, 143 
diagnosis, 143 

in first half, 145 
in second half, 159 
differential diagno-sis, 163, 169, 311 

from pregnancy, 133 
free internal hemorrhage, 163 
gestation in rudimentary comu, 173 
interstitial gestation, 173 
perforation peritonitis in, 163 
rarer forms, 173 
tubal, 143, 145 
undisturbed, 145 
fetal heart sounds, 129 

movements, 129, 131 
histologic changes in, 113 
intact hjinen, 636 
intestinal, 143 

intra-uterine, differential diagnosis, 169 
menstruation during, 131 
micro.scopic diagnosis, 175 
nausea in, 131 
normal, diagnosis, 124 

during first half of gestation, 
124 
ovarian, 143 
tubal, 463, 464 

differential diagnosis, 164, 165, 166, 

167, 168 
encapsulated hemorrhage in, 147 
free internal hemorrhage in, 146 
hematoma of the broad ligament, 

151 
history-, 154 



666 



GENERAL INDEX 



Pregnancy, tubal, immediate operation in, 156 
intraligamentary, 151, 161 
objective signs of, 152, 154 
peritubal hematocele, 150, 151 
retro-uterine hematocele, 148, 149 
stage of, 156 

subjective symptoms, 155 
symptomatology, 154 
tubo-ovarian, 143 
tubo-uterine, 143 
vomiting 4n, 131 
Prepuce, 77 
Prickle cells, 98 

Profanter's method of examination, 10 
Prolapse of the anterior vaginal wall, 221 
of the posterior vaginal wall, 221 
of the uterus, 218 
of the vagina, 221 
Pruritus vulvae, 520 
Pseudohermaphroditismus masculinus exter- 

nus, 549 
Pseudotumors, differential diagnosis, 312 
Psoriasis of the uterine mucosa, 429 
Pyelitis, 589, 590 

descending, 586 
Pyogenic micro-organisms, 67 
Pyometra unilateralis, 554 
Pyonephrosis, 592 
Pyosalpinx, 456, 457, 459, 463, 467 
differential diagnosis, 488 
gonorrhea^ 524 
perforation of, 468 
Pyuria, 56 

Radiography, 68 

in examination for foreign bodies, 586 
for stone, 584 
Rectocele, 222, 232 
Recto-uterine ligaments, 87 

pouch, 83 
Rectovaginal septum, 546 
Rectum, 94 

fold of Kohlrausch, 95 
palpation, 95 
Retention after abortion, Hegar's sign in, 129 
diagnosis from intact ovum, 141 
tumors (see also under Tumors), 453, 454 
Retroflexion of the gravid uterus, 250 

differential diagnosis, 167, 168, 
304 
Retro-uterine hematocele, differential diag- 
nosis, 167 
Retroversioflexion, bladder in, 245 
symptoms in, 249 
complications, 248 



Retroversioflexion, diagnosis, 246 

differential diagnosis, 247 

dysmenorrhea in, 250 

nervous symptoms in, 250 

ovaries in, 245 

retroflexion of the gravid uterus, 250 

sterility in, 250 
, tubes in, 245 

uterine body in, 244 

vagina in, 242 

vaginal portion in, 243 
Rima pudendi, 546 
Rubber glove examination, 12 
Rudimentary cornu, gestation in, 173 
Round ligaments, 85, 87 

Sacro-uterine (recto-uterine) ligaments, 85, 87 

Sacral glands, 96 

Sacrum, 76 

Salpingitis, catarrhal, 449, 450 

cause of sterility, 643 

gonorrheal, 466 

purulent, 452 

septic, 466 

tuberculous, 467 
Sarcoma, complicating myoma, 289 

differential diagnosis, 198, 431 

mural, 373 

ovarian, 333 

urethral, 563 
Schenk, 633 
Schliff, 629 
Schniirleber, 320 
Schrumpfblase, 570 
Schultze, 504, 505 
Schultze's retroversio cum anteflexione, 244 

tampon, 504 
Sebaceous glands, histology, 98 
Semen, examination of, 634 
Senescentia precox, histology, 529 
Serotina, 177, 184 
Sellheim, 20, 321, 324 
Shadow of the uterus, 94 
Sigmoid flexure, 95 
Signs of pregnancy, early, 125-129 

late, 129-131 
Simon's or Sims' speculum, 24 

speculum, 22, 23, 25 

urethral specula, 20 
Simpson, 632 
Sims' position, 10 

speculum, 22, 23, 25 
Skene's ducts, 77 

glands, 103 
Sound, accidents, 28 



GENERAL INDEX 



667 



Sound, contraindications to, 27-29 

diagnosis of abortion, 142 

indications, 29-32 

technic of the introduction of, 26 

uterine, 26 
Sounding, in diagnosis of myomata, 274 

in diseases of the urethra, 559 
Special diagnosis, 76 
Specula, 22 

bivalve, 25 

Kelly, 59 

method of introducing, 23 
of using, 20 

Simon's, 23 

or Sims', 23, 24 
urethral, 20 

trivalve, 25 
Spee, 201 
Spiegelberg, 401 
Spuler, 422 
Staphylococci, 67 
Steinbuchel, 39 
Sterility, 546 

causes of, 632-646 
history, 646 

definition, 632 
Stockel, 54, 55, 94 
Streptococci, 67 
Sweat glands, histology, 99 
Syncytial layer, 181, 183, 184, 185, 188, 422 

wander cells, 202 
Syncytioma benignum, 183, 200 

ectodermal e (masculinum), 423 

malignant, 187, 200.. 373, 421, 422, 424, 
425, 428 
differential diagnosis, 431 

nomenclature of, 426 
Syncytium, ISO, 181, 202 

Tampons, Schultze's, 504 
Tenesmus vesicae, 563 

causes, 563, 571 
definition, 563 
Teratomata, 333 

Thrush of the vaginal mucous membrane, 519 
Transformation of the cervix, doctrine of, 

203-205 
Trendelenburg position, 10 
Trichomonas vaginalis, 43 
Trigonum, 93 
Trivalve speculum, 25 
Tubal cord, 459 

diseases, definition, 449 

pregnancy, 463, 464 
Tubercle bacilh, 65 



Tuberculosis, diagnosis of, 65 

of ureter, 587 
Tumors, abdominal, analytical diagnosis, 
647-656 
large, 647 
abdominal wall, differential diagnosis, 

308 
adnexal, in gonorrhea, 524 
bladder, 580-583 
cystoscopy, 581 
hemorrhage, 580 
cystic ovarian, 462 
cystoscopy in renal, 595, 596 
dermoid, 331, 332 
intraligamentary, 655 
liver, differential diagnosis, 320 
mesenteric, differential diagnosis, 319 
myxoid ovarian, differential diagnosis, 
315 
percussion of, 315 
ovarian, 293, 652, 655 
adhesions, 324 
classification of, 293, 298 
complications, 321-328 
definition of, 293 
diagnosis, 289, 293, 305 
of malignancy, 327 
of variety of, 328-333 
differential diagnosis, 293, 300-304, 
308 
from pregnancy, 133 
intraligamentary, 295, 296, 322 

differential diagnosis, 303 
large, differential diagnosis, 312-321 
medium-sized, 305 
diagnosis, 305 

differential diagnosis, 307-312 
retroligamentary, 296 
retro-uterine, 304 
rupture of, 325 
small, 299 
suppuration of, 326 
torsion-pedicle, 325 
para-uterine, 651 
parovarian, 655 
pelvic, 652 
position of renal, 593 
renal, 592, 594 

catheterization of the ureters in, 595 
differential diagnosis, 596, 597 
retention, 453, 454, 554, 592 

symptomatology, 555 
retroperitoneal, differential diagnosis, 319 
retro-uterine ovarian, 477 
splenic, differential diagnosis, 319 



668 



GENERAL INDEX 



Tumors, tubal, 655 

urethral, see under Urethra, 
uterme, 651 

TJlcer, carcinomatous, differential diagnosis, 
352 

cerAdcal, 543 

decubital, differential diagnosis, 353 

erosion, histology of, 404 

rodent, 387 

simple, 353 

sj^phUitic, 354 

differential diagnosis, 354 
histology of, 404 

tuberculous, histology of, 404 
Ulcera mollia, 354 
Ulceration, tuberculous, chfferential diagnosis, 

353 
Ulcus chronicum, 387 

elephantiasticimi, 387 ~~ 
Ureteral orifices, 93 
Ureteritis, 5S6 

cystoscojjy in, 586 
Ureters, 94 

catherization of, 56, 57, 595 

catherization of in dystopia of the kid- 
neys, 600 

compression of, 589 

diseases of, 57, 586 

fistulse, 57 

gonorrhea of, 587 

injuries of, 586, 587, 588, 589 

ligation of, 588 

occlusion, 57 

operative di\"ision of, 589 

palpation of. 94 

tuberculosis of, 587 
Urethra, 77 

calculi, 563 

foreign bodies in, 563 

carcinoma, primary, 562 

diseases of, 558-563 

fibroma of, 563 

foreign bodies in, 563 

liistology, 103 

inspection of, 558 

operative opening of, 560 

palpation of, 558 

prolapse of, 562 

sarcoma of, 563 

secretion of, 558 

tumors of, 561 
Urethral fimgus, 447 

orifice, dilatation of, 60 
Urethritis, 560 



Urethritis, recent purulent, in gonorrhea, 523 
Urethrocele, 231 

Urinary apparatus, diseases of, diagnosis, 
557-601 
injuries of, 572 
physiology, 557 
Urine, evacuation of, 557 

examination of, 560, 564—566 

Thompson's two glass method, 560 
separator, 591 
Urogenital sinus, 546 
Uterine body, 80 

adenoma, malignant, 414, 415, 417, 

418 
blood-vessels, 121 
carcinoma of, 337 
adenoid, 415 
circumscribed, 343 
differential diagnosis, 426 
diffuse, 342 
histology of, 413 
polypoid, 343 
hemorrhage from, 609 
histology, 106, 118 
mucous carcinoma, 372 
musculature of, 118, 119 
retroversioflexion, 244 
sarcoma of, 370 
cavity, atresia, 641 

digital exploration of, 37 
dilatation and palpation of, 32 
indications, 34 
instnmiental, 35 
technic, 34 
liistology, 107 
measuring of, 31 
palpation, 37 
stenosis, 641 
displacement, diagnosis of, 229 
glands. 111, 113, 114 
hemorrhage, diagnosis of, 33 
mucous membrane histology. 111, 114, 

115 
myomata, 258 
soimd, 26 
tumors, 651 
Uterovaginal plexus, 98 
Uterus, 80, 84 

anteflexion, 237 
anteposition, 212 
anteversion, 234 
arcuatus, 552 
bicornis, 552 

duplex, 551, 553 
infrasimplex, 553 



GENERAL INDEX 



669 



Uterus bicornis unicollis, 552, 553 

uniforis, 551, 553 
carcinoma of, 337 

diagnosis and differential diagnosis, 
344 

physical signs, 346 

sjTnptoms, 345 
changes in consistency during preg- 
nancy, 128 

during pregnancy, 126 
chorionepithelioma of, 373 

clinical pictures and lines of exten- 
sion, 373 

diagnosis and differential diagnosis, 
374 

metastasis in, 375 
chronic puerperal inversion, 256 
complete absence of, 548 
descent, 219, 225 
dextroposition, 215 
didelphys, 551, 552, 553 
displacement of, 211 

cause of sterility, 641 
double, 552 

formation of, diagnosis, 551-556 
elevation, 217 

enlargement during pregnancy, 126 
fibrosarcoma, 433 
flexion, 212 
foetalis, 549 
hernia, 212 
histology, 106 

imperfect development, diagnosis, 546- 
550 
dysmenorrhea in, 627 
infantilis, 549 

instrumental reposition, 253, 254 
interior of, see Uterine cavity. 
inversion, 212, 219, 256 

differential diagnosis, 257 
lateroposition, 215 
lateroversion, 235 

acquired, 236 

congenital, 236 
line of firm attachment of peritoneum, 

120, 121, 122 

loose attachment of peritoneum, 

121, 122 
lymphatics, 121 
manual reposition, 252 
palpation of, 85, 587 
peritoneal covering of, 121 
positions of, 211 
prolapse, 218, 219, 22*5, 230 

differential diagnosis, 233 



Uterus, retractor muscle, 85 
retroposition, 213 

and laterodisplacement, 214 
retroversioflexion, 241 
retroversion, 237 
rotation, 212 

rudimentaris bipartitus, 549 
sarcoma of, 370 

clinical pictures and lines of exten- 
sion, 370 

diagnosis and differential diagnosis, 
372 

giant-cell, 433 

histology of, 431 

large-ceil, 432 

small round cell, 433 

spindle cell, 432 
septus, 552 

biforis, 551 
sinistroposition, 215 
softening during pregnancy, 127 
sounding of, 26 
subseptus, 552 

unicollis, 552 

unicorporeus, 552 

uniforis, 552 
torsion, 212, 255 
unicornis, 553, 554 
versions, 211 

Vagina, 76, 78, 79, 84 

carcinoma, histology of, 436, 437 

primary, 377 

secondary, 377 
changes during pregnancy, 125 
circular stenoses of, 637 
descent, 221 

displacement, diagnosis, 224 
double, 551, 637 

formation of, diagnosis, 551-556 
fibromyomata, 377 
histology, 104 
imperfect development of, diagnosis, 

546-550 
inversion, 223, 224 

and descent, 224 
muscularis of, 106 
neoplasms of, 377 
prolapse, 221, 223 
retroversioflexion, 242 
sarcoma of, 379 

histology of. 437 
septa, 551 

total absence of, 637 
tuberculosis, differential diagnosis, 378 



\\ -^Vi 



»*-_ 



670 



GENERAL INDEX 






Vaginal glands, 104 
portion, 79, 80, 81 

carcinoma of, 337, 347 

cauliflower tumors. 347 
differential diagnosis, 349 
histology of, 401 
infiltrating, 338 
polypoid, 338 
carcinomatous cavity, 339 
ulcer, 339 
" ulceration, 348 
carcinosarcoma, histology of, 405 
changes during pregnancy, 126 
condylomata, 409 
erosion ulcers, 405 
fibromata, histology of, 405 
fibromyomata, histology of, 405 
follicular hypertrophy of, differen- 
tial diagnosis, 351 
hemorrhage from, 608 
histology, 106, 107, 120, 401 
myomata, histology of, 405 
papillomata, histology of, 405 
papillary tuberculosis, differential 

diagnosis, 349 
proliferations, 409 
retroversioflexion, 243 
sarcoma, 370, 372 
softening in pregnancy, 126 
verrucose, 409 
Vaginism, 637 
Vaginitis, exfoliative, 209 
Van Swieten, 124 
Veins, hypogastric, 98 
palpation of, 98 
pampiniform plexus, 98 
spermatic, 98 
uterine, 98 

uterovaginal plexus, 98 
Veit-Schroder 's chair, 6 
Vesico-uterine pouch, 83 



Vestibule (vestibulum vaginae), 77 
Villous attachment, 201, 202 

hood, 183 
Volcker and Joseph, 55 
Von Hoffmann, 118 
Von Preuschen, 104 

glands, 105 
Von Winicel, 546 
Vulva, 76 

cancroids, 382 
carcinoma, cancroid, 381 
histology of, 436, 437 
infiltrating, 381, 382 
carcinomatous ulcers, 382 
condylomata lata, 386 
fibromata, 380 
histology, 98 
lipomata, 381 
neoplasms of, 380 

classification, 380 
sarcoma, 381 

histology of, 437 
syphilitic primary sore, 386 
ulcerations of, 380, 385 
classification, 380 
carcinomatous, 385 
syphilitic, 386 
tuberculous, 386 
Vulvitis, 501, 519 
catarrhal, 519 
maculosa, 520 
pruriginosa, 520 

Waldeyer-Thiersch, 401 
Wertheim, 465 
Witte, 465 
Wolffian body, 545 
duct, 105, 545 

Zangemeister, 585 
Ziilzer, 633 



